Healthcare Provider Details

I. General information

NPI: 1316117047
Provider Name (Legal Business Name): MARCIA MARIE NIELSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 SW 12TH AVE
PORTLAND OR
97205-2329
US

IV. Provider business mailing address

10345 NE CLACKAMAS ST APT 16
PORTLAND OR
97220-3997
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-7134
  • Fax:
Mailing address:
  • Phone: 503-408-7683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number000043616N6
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: