Provider Demographics
NPI:1093724965
Name:NELISSEN, DEBRA JEAN (OD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:NELISSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:JEAN
Other - Last Name:MCNAMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PSC 7 BOX 417
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09104-0005
Mailing Address - Country:US
Mailing Address - Phone:01149160-692-9161
Mailing Address - Fax:
Practice Address - Street 1:725 ACES PLACE
Practice Address - Street 2:BOX 79
Practice Address - City:RIGGINS
Practice Address - State:ID
Practice Address - Zip Code:83549
Practice Address - Country:US
Practice Address - Phone:208-628-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist