Basic Information
| Provider Information | |||||||||
| NPI: | 1093729873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSEN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | STE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14410 SE PETROVITSKY RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980588900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569034054 | ||||||||
| FaxNumber: | 4256909405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | MD00035357 | WA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207Q00000X | MD00035357 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1042822 | 05 | WA | MEDICAID | G8891361 | 01 | WA | MEDICARE W VALLEY MEDICAL GROUP - RENTON | OTHER |