Provider Demographics
NPI:1114657491
Name:NELSON, ELIZABETH MARIE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 RED MAPLE WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3746
Mailing Address - Country:US
Mailing Address - Phone:252-626-3138
Mailing Address - Fax:
Practice Address - Street 1:4400 E HIGHWAY 20 STE 207
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-7700
Practice Address - Country:US
Practice Address - Phone:850-897-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA75408225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist