Provider Demographics
NPI:1649900663
Name:NIELSEN, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:840 SW 4TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2638
Practice Address - Country:US
Practice Address - Phone:418-892-6685
Practice Address - Fax:541-889-2997
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant