Provider Demographics
NPI:1851462717
Name:NIELSEN, THERESA F (FNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:F
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-4900
Mailing Address - Fax:800-852-3264
Practice Address - Street 1:2960 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-4900
Practice Address - Fax:800-852-3264
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128179363LF0000X
CT6696363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1851462717Medicaid
VAVAA103576Medicare PIN