Provider Demographics
NPI:1073720868
Name:NELSON, KRISTEN MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3363
Mailing Address - Country:US
Mailing Address - Phone:479-968-2345
Mailing Address - Fax:479-890-7169
Practice Address - Street 1:101 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3363
Practice Address - Country:US
Practice Address - Phone:479-968-2345
Practice Address - Fax:479-890-7169
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6533208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185138001Medicaid
AR5AF97C963Medicare PIN