Provider Demographics
NPI:1144619594
Name:NELSON, AGATA (LM)
Entity Type:Individual
Prefix:MRS
First Name:AGATA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 S 8TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3744
Mailing Address - Country:US
Mailing Address - Phone:904-875-4278
Mailing Address - Fax:904-572-1571
Practice Address - Street 1:910 S 8TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3744
Practice Address - Country:US
Practice Address - Phone:904-875-4278
Practice Address - Fax:904-572-1571
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL305207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics