Healthcare Provider Details

I. General information

NPI: 1396938411
Provider Name (Legal Business Name): TAMARA LYNN NIELSON LMT, MLD/CDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33841 SE DUUS RD
ESTACADA OR
97023-8820
US

IV. Provider business mailing address

PO BOX 1427
ESTACADA OR
97023-1427
US

V. Phone/Fax

Practice location:
  • Phone: 503-318-6799
  • Fax: 503-630-7431
Mailing address:
  • Phone: 503-318-6799
  • Fax: 503-630-7431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14141
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: