Provider Demographics
NPI:1568071074
Name:NELSON, NICOLE RAEANNE (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAEANNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-1549
Mailing Address - Country:US
Mailing Address - Phone:360-581-3655
Mailing Address - Fax:
Practice Address - Street 1:516 E 1ST ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4106
Practice Address - Country:US
Practice Address - Phone:360-986-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61083726164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse