Provider Demographics
NPI:1821028333
Name:NELSON, DIANE M (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:KIRCHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:803 VANDERCOOK WAY STE 2
Mailing Address - Street 2:LOWER COLUMBIAN OCCUPATIONAL HEALTH
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4039
Mailing Address - Country:US
Mailing Address - Phone:360-414-8818
Mailing Address - Fax:360-414-8088
Practice Address - Street 1:803 VANDERCOOK WAY STE 2
Practice Address - Street 2:LOWER COLUMBIA OCCUPATIONAL HEALTH
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4039
Practice Address - Country:US
Practice Address - Phone:360-414-8818
Practice Address - Fax:360-414-8088
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005429363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9626045Medicaid
S97478Medicare UPIN
WA9626045Medicaid