Basic Information
| Provider Information | |||||||||
| NPI: | 1235553801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | ELOISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIMES | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | ELOISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291253 | ||||||||
| FaxNumber: | 3607293185 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 HILYARD ST STE 450 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4582057131 | ||||||||
| FaxNumber: | 5416876214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2014 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201804601NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | APRN002061 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | CNP-02348 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1235553801 | 05 | NV | MEDICAID |