Provider Demographics
NPI:1346493723
Name:NELSON, DEANNA J
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:J
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 1:5200 FAIRVIEW BOULEVARD
Mailing Address - Street 2:FAIRVIEW SPORTS AND ORTHOPEDIC CARE
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092
Mailing Address - Country:US
Mailing Address - Phone:651-982-7495
Mailing Address - Fax:651-982-7539
Practice Address - Street 1:5200 FAIRVIEW BOULEVARD
Practice Address - Street 2:FAIRVIEW SPORTS AND ORTHOPEDIC CARE
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092
Practice Address - Country:US
Practice Address - Phone:651-982-7495
Practice Address - Fax:651-982-7539
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer