Healthcare Provider Details

I. General information

NPI: 1043554181
Provider Name (Legal Business Name): MICHELLE LYN NELSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 TUTTLE LN
BURBANK WA
99323-9717
US

IV. Provider business mailing address

386 TUTTLE LN
BURBANK WA
99323-9717
US

V. Phone/Fax

Practice location:
  • Phone: 509-302-1459
  • Fax:
Mailing address:
  • Phone: 509-302-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number00001513
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: