Provider Demographics
NPI:1447027370
Name:NIELSEN, NICOLE MARIAH (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIAH
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10811 SE KENT KANGLEY RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7108
Mailing Address - Country:US
Mailing Address - Phone:253-854-5660
Mailing Address - Fax:
Practice Address - Street 1:29020 216TH AVE SE
Practice Address - Street 2:
Practice Address - City:BLACK DIAMOND
Practice Address - State:WA
Practice Address - Zip Code:98010-1274
Practice Address - Country:US
Practice Address - Phone:253-854-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT614896202251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics