Provider Demographics
NPI:1619391976
Name:NELSON, DIANNE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82688
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-0688
Mailing Address - Country:US
Mailing Address - Phone:206-650-0077
Mailing Address - Fax:
Practice Address - Street 1:6426 NE 182ND ST
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-4813
Practice Address - Country:US
Practice Address - Phone:206-650-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00021609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH00021609OtherPHARMACIST LICENSE