Healthcare Provider Details

I. General information

NPI: 1114351848
Provider Name (Legal Business Name): NIKKI LEE HARTLEY-JONASON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. NIKKI LEE HARTLEY-JONASON

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 BAY AVE STE 201
OCEAN PARK WA
98640-4203
US

IV. Provider business mailing address

PO BOX H
ILWACO WA
98624-0258
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3747
  • Fax: 360-642-3361
Mailing address:
  • Phone: 360-642-6387
  • Fax: 360-642-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60669740
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: