Provider Demographics
NPI:1093282741
Name:NELSON, REAGAN (AE-C)
Entity Type:Individual
Prefix:MS
First Name:REAGAN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:AE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S BIG BEND BLVD STE 1S
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-2212
Mailing Address - Country:US
Mailing Address - Phone:314-645-2422
Mailing Address - Fax:314-645-2022
Practice Address - Street 1:1500 S BIG BEND BLVD STE 1S
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-2212
Practice Address - Country:US
Practice Address - Phone:314-645-2422
Practice Address - Fax:314-645-2022
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1114394145Medicaid