Provider Demographics
NPI:1801147277
Name:DANIELSON, NICHOL MARIE (LMP)
Entity type:Individual
Prefix:MISS
First Name:NICHOL
Middle Name:MARIE
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MISS
Other - First Name:NICHOL
Other - Middle Name:MARIE
Other - Last Name:WESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1905 SE 192ND AVE.
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607
Mailing Address - Country:US
Mailing Address - Phone:360-253-6503
Mailing Address - Fax:360-954-5413
Practice Address - Street 1:1905 SE 192ND AVE.
Practice Address - Street 2:SUITE 111
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607
Practice Address - Country:US
Practice Address - Phone:360-253-6503
Practice Address - Fax:360-954-5413
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60305909225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist