Provider Demographics
NPI:1275077018
Name:NELSON, MIRLANDE (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:MIRLANDE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 MATTERHORN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-5858
Mailing Address - Country:US
Mailing Address - Phone:407-879-0438
Mailing Address - Fax:
Practice Address - Street 1:501 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818
Practice Address - Country:US
Practice Address - Phone:407-879-0438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management