Provider Demographics
NPI:1225437734
Name:ANSLOW, NELLYDA M (AGPCNP)
Entity type:Individual
Prefix:
First Name:NELLYDA
Middle Name:M
Last Name:ANSLOW
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 N ROOSEVELT DR
Mailing Address - Street 2:STE 104
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-7044
Mailing Address - Country:US
Mailing Address - Phone:503-717-7150
Mailing Address - Fax:
Practice Address - Street 1:1150 N ROOSEVELT DR
Practice Address - Street 2:STE 104
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:541-754-1150
Practice Address - Fax:503-717-7159
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201408083NP-PP363LA2200X, 363LG0600X
OR200641338RN363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5451211OtherOR DRIVERS LICENSE
OR5451211OtherOR DRIVERS LICENSE
OR93-0635514OtherGROUP TAX ID NORTH BEND MEDICAL CENTER
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER