1831238351 NPI number — MARTHA E NELSON

Table of content: MARTHA E NELSON (NPI 1831238351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831238351 NPI number — MARTHA E NELSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
MARTHA
Provider Middle Name:
E
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:
WAKENSHAW
Provider Other First Name:
MARTHA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1831238351
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:
712 N 165TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHORELINE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98133-5302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-771-5166
Provider Business Mailing Address Fax Number:
425-670-2807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
547 DAYTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98020-3431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-771-5166
Provider Business Practice Location Address Fax Number:
425-670-2807
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: 101YM0800X , with the licence number:  LH00004619 , 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: 2858WA . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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