Provider Demographics
NPI:1043091598
Name:NELMS, MARY ELLEN (LDO)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:NELMS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1455 HIGHWAY 441 S
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-7607
Mailing Address - Country:US
Mailing Address - Phone:706-782-6961
Mailing Address - Fax:706-782-6966
Practice Address - Street 1:1455 HIGHWAY 441 S
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-7607
Practice Address - Country:US
Practice Address - Phone:706-782-6961
Practice Address - Fax:706-782-6966
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO1036156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician