Provider Demographics
NPI:1699232538
Name:CHARLSON, NIKKI MARIE
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:MARIE
Last Name:CHARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19323 NE 214TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3724
Mailing Address - Country:US
Mailing Address - Phone:360-984-4621
Mailing Address - Fax:
Practice Address - Street 1:8221 NE HAZEL DELL AVE STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8153
Practice Address - Country:US
Practice Address - Phone:360-977-6090
Practice Address - Fax:360-836-5659
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60888527225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60888527OtherMASSAGE THERAPY