Healthcare Provider Details

I. General information

NPI: 1952069189
Provider Name (Legal Business Name): KRYSTLE MARIE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTLE MARIE HOLCOMB

II. Dates (important events)

Enumeration Date: 12/05/2021
Last Update Date: 12/05/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WESTLAKE AVE N STE 400
SEATTLE WA
98109-6211
US

IV. Provider business mailing address

5858 POPPY HILLS ST SE
SALEM OR
97306-9011
US

V. Phone/Fax

Practice location:
  • Phone: 206-301-5000
  • Fax:
Mailing address:
  • Phone: 509-264-6939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60741716
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: