Provider Demographics
NPI:1720252505
Name:NIELSEN, JUDITH ANN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANN
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11258 SE 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6712
Mailing Address - Country:US
Mailing Address - Phone:503-729-7349
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-2302
Practice Address - Fax:360-414-2305
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007740363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9657727Medicaid
OR025976Medicaid
WA237808OtherLABOR & INDUSTRIES
OR025976Medicaid