1699232538 NPI number — NIKKI MARIE CHARLSON

Table of content: NIKKI MARIE CHARLSON (NPI 1699232538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699232538 NPI number — NIKKI MARIE CHARLSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLSON
Provider First Name:
NIKKI
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699232538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19323 NE 214TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE GROUND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98604-3724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-984-4621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8221 NE HAZEL DELL AVE STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-8153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-977-6090
Provider Business Practice Location Address Fax Number:
360-836-5659
Provider Enumeration Date:
02/27/2019

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: 225700000X , with the licence number:  MA60888527 , 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: MA60888527 . This is a "MASSAGE THERAPY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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