Basic Information
| Provider Information | |||||||||
| NPI: | 1821028333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIRCHNER | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 803 VANDERCOOK WAY STE 2 | ||||||||
| Address2: | LOWER COLUMBIAN OCCUPATIONAL HEALTH | ||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986324039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604148818 | ||||||||
| FaxNumber: | 3604148088 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 VANDERCOOK WAY STE 2 | ||||||||
| Address2: | LOWER COLUMBIA OCCUPATIONAL HEALTH | ||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986324039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604148818 | ||||||||
| FaxNumber: | 3604148088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0106X | AP30005429 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Occupational Health |
ID Information
| ID | Type | State | Issuer | Description | 9626045 | 05 | WA | MEDICAID |