Provider Demographics
NPI:1730565623
Name:NELSON, SARAH COLLEEN (LMT)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:COLLEEN
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:PIERCE
Mailing Address - State:ID
Mailing Address - Zip Code:83546-0161
Mailing Address - Country:US
Mailing Address - Phone:208-464-1334
Mailing Address - Fax:208-476-0711
Practice Address - Street 1:162A RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9066
Practice Address - Country:US
Practice Address - Phone:208-476-7091
Practice Address - Fax:208-476-0711
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist