Healthcare Provider Details

I. General information

NPI: 1437530656
Provider Name (Legal Business Name): RANDI NIELSEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 NW 11TH ST
HERMISTON OR
97838-6600
US

IV. Provider business mailing address

702 SUNSET DR
ONTARIO OR
97914-3121
US

V. Phone/Fax

Practice location:
  • Phone: 541-567-2536
  • Fax:
Mailing address:
  • Phone: 541-889-9167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberAP60623651
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number111815
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201710044NPPP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: