1205975612 NPI number — MRS. CAROL KAY NELSON MS CCC

Table of content: MRS. CAROL KAY NELSON MS CCC (NPI 1205975612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205975612 NPI number — MRS. CAROL KAY NELSON MS CCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
CAROL
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS CCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LYON
Provider Other First Name:
CAROL
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205975612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8410 45TH ST W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIVERSITY PLACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-564-5506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33515 10 PL S
Provider Second Line Business Practice Location Address:
13 CC MANNING AND ASSOCIATES
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-7300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-874-2599
Provider Business Practice Location Address Fax Number:
253-874-2392
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  LL00001754 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8338469 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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