Provider Demographics
NPI:1871754762
Name:NELSON, //BRENDA KAY (MED)
Entity type:Individual
Prefix:
First Name://BRENDA
Middle Name:KAY
Last Name:NELSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-4625
Mailing Address - Country:US
Mailing Address - Phone:580-286-5184
Mailing Address - Fax:580-286-5185
Practice Address - Street 1:17 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4625
Practice Address - Country:US
Practice Address - Phone:580-286-5184
Practice Address - Fax:580-286-5185
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist