Provider Demographics
NPI:1003877317
Name:NELSON, LISA MARGARET (AUD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARGARET
Last Name:NELSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MITCHELLVILLE RD
Mailing Address - Street 2:B124
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3104
Mailing Address - Country:US
Mailing Address - Phone:301-464-2036
Mailing Address - Fax:301-464-9226
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:B124
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-464-2036
Practice Address - Fax:301-464-9226
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD594231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD780LMedicare PIN
DCG00024Medicare PIN