Provider Demographics
NPI:1841176310
Name:NELSON, DE' MARIEYA
Entity type:Individual
Prefix:
First Name:DE' MARIEYA
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 SHORELAKE CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2036
Mailing Address - Country:US
Mailing Address - Phone:209-242-1189
Mailing Address - Fax:
Practice Address - Street 1:4011 SHORELAKE CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2036
Practice Address - Country:US
Practice Address - Phone:209-242-1189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach