Provider Demographics
NPI:1760008908
Name:NEELY, TANYA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:NEELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:MARSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:131 MCKALL CT
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-2256
Mailing Address - Country:US
Mailing Address - Phone:360-749-9120
Mailing Address - Fax:855-790-9134
Practice Address - Street 1:4550 KRUSE WAY STE 125
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3533
Practice Address - Country:US
Practice Address - Phone:503-369-3135
Practice Address - Fax:855-790-9134
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60137227163WC0200X
WAAP61127888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine