Provider Demographics
NPI:1124549100
Name:NELSON, NIESHA R (NP-C)
Entity Type:Individual
Prefix:DR
First Name:NIESHA
Middle Name:R
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 S 3000 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6977
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:
Practice Address - Street 1:6405 S 3000 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6977
Practice Address - Country:US
Practice Address - Phone:801-266-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7667592-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7667592-4405OtherAPRN LICENSE