Provider Demographics
NPI:1801008743
Name:NELSON, WANDA JEAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:JEAN
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 S. COLLEGE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324
Mailing Address - Country:US
Mailing Address - Phone:509-527-2425
Mailing Address - Fax:
Practice Address - Street 1:133 S COLLEGE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1193
Practice Address - Country:US
Practice Address - Phone:509-527-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPO4405Medicare UPIN