Healthcare Provider Details

I. General information

NPI: 1497905152
Provider Name (Legal Business Name): CHANTEL LOUISE NELSON LMP, ACSM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 N MONTESANO STREET
WESTPORT WA
98595
US

IV. Provider business mailing address

PO BOX 968
WESTPORT WA
98595-0968
US

V. Phone/Fax

Practice location:
  • Phone: 360-500-9970
  • Fax:
Mailing address:
  • Phone: 360-500-9970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00016401
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: