Provider Demographics
NPI:1083612436
Name:NELSON, MARIE S (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:S
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 VETERANS WAY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-1000
Mailing Address - Country:US
Mailing Address - Phone:850-912-2277
Mailing Address - Fax:850-912-2497
Practice Address - Street 1:790 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507
Practice Address - Country:US
Practice Address - Phone:850-912-2277
Practice Address - Fax:850-912-2497
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001597213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4480692Medicaid
MI4480692Medicaid
MI0P15240001Medicare PIN