Healthcare Provider Details

I. General information

NPI: 1801008743
Provider Name (Legal Business Name): WANDA JEAN NELSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 S COLLEGE AVE SUITE 101
COLLEGE PLACE WA
99324-1193
US

IV. Provider business mailing address

133 S. COLLEGE AVE SUITE 101
COLLEGE PLACE WA
99324
US

V. Phone/Fax

Practice location:
  • Phone: 509-527-2425
  • Fax:
Mailing address:
  • Phone: 509-527-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP30005582
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: