Provider Demographics
NPI:1932830619
Name:NELSON, MIRANDA (APRN)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:MO
Mailing Address - Zip Code:63965
Mailing Address - Country:US
Mailing Address - Phone:573-323-4253
Mailing Address - Fax:573-323-4465
Practice Address - Street 1:405 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:MO
Practice Address - Zip Code:63965
Practice Address - Country:US
Practice Address - Phone:573-323-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022021774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily