Provider Demographics
NPI:1003248113
Name:ENGLEDOW, NICOLE M (ARPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:ENGLEDOW
Suffix:
Gender:
Credentials:ARPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 S. 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328
Mailing Address - Country:US
Mailing Address - Phone:509-382-2531
Mailing Address - Fax:502-382-3205
Practice Address - Street 1:500 8TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2691
Practice Address - Country:US
Practice Address - Phone:208-792-2685
Practice Address - Fax:208-792-2882
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1307A363LF0000X
WAAP60454197363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032544Medicaid