Provider Demographics
NPI:1801925227
Name:NELSON, KYLE ALLEN (MPH, ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ALLEN
Last Name:NELSON
Suffix:
Gender:M
Credentials:MPH, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17705 SE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1918
Mailing Address - Country:US
Mailing Address - Phone:360-891-8199
Mailing Address - Fax:
Practice Address - Street 1:5000 N WILLAMETTE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-5743
Practice Address - Country:US
Practice Address - Phone:503-943-7747
Practice Address - Fax:503-943-7532
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08213607562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer