Provider Demographics
NPI:1043660806
Name:NELSON, NICKESHA
Entity type:Individual
Prefix:
First Name:NICKESHA
Middle Name:
Last Name:NELSON
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 1:901 45TH ST
Mailing Address - Street 2:
Mailing Address - City:MANGONIA PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2413
Mailing Address - Country:US
Mailing Address - Phone:561-840-6013
Mailing Address - Fax:
Practice Address - Street 1:901 45TH ST
Practice Address - Street 2:
Practice Address - City:MANGONIA PARK
Practice Address - State:FL
Practice Address - Zip Code:33407-2413
Practice Address - Country:US
Practice Address - Phone:561-840-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9314126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
9310146OtherARNP