Provider Demographics
NPI:1760430151
Name:NIELSEN, AMY M (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S UNION AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3209 S 23RD ST STE 340
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007085367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8912172OtherMDCR PTAN (P)
WAG8894620OtherMDCR PTAN (K)
WIS52838Medicare UPIN