Provider Demographics
NPI:1063879088
Name:NIKOLAO, ALYSE (FNP, CNM)
Entity type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:NIKOLAO
Suffix:
Gender:F
Credentials:FNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7501
Mailing Address - Fax:253-274-7926
Practice Address - Street 1:1608 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4930
Practice Address - Country:US
Practice Address - Phone:253-274-7501
Practice Address - Fax:253-274-7926
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60436839163W00000X
WAAP60932557363L00000X, 367A00000X
WAAP60932559367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2132960Medicaid