Provider Demographics
NPI:1174839344
Name:NELSON, MICHELLE RENEE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:NELSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:TRACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:19601 CHEROKEE ROAD
Mailing Address - Street 2:P.O. BOX 435
Mailing Address - City:TUOLUMNE
Mailing Address - State:CA
Mailing Address - Zip Code:95379-0435
Mailing Address - Country:US
Mailing Address - Phone:209-928-9248
Mailing Address - Fax:
Practice Address - Street 1:4525 W TULARE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-1560
Practice Address - Country:US
Practice Address - Phone:530-781-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA-689174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist