Basic Information
Provider Information | |||||||||
NPI: | 1124557715 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIELSEN | ||||||||
FirstName: | MARGIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP, FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ECCLESTON | ||||||||
OtherFirstName: | MARGIE | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 SW 13TH AVE | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972051999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032210161 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15950 SW MILLIKAN WAY | ||||||||
Address2: |   | ||||||||
City: | BEAVERTON | ||||||||
State: | OR | ||||||||
PostalCode: | 970035170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036460161 | ||||||||
FaxNumber: | 5036437459 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2017 | ||||||||
LastUpdateDate: | 08/31/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/31/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 201707942 | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | AP60889600 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LF0000X | 202100467NP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.