Provider Demographics
NPI:1457492944
Name:NELSON, ANDREA PAULINE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:PAULINE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 BLOOMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3665
Mailing Address - Country:US
Mailing Address - Phone:612-825-1230
Mailing Address - Fax:612-861-1533
Practice Address - Street 1:2400 W 64TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55423-1001
Practice Address - Country:US
Practice Address - Phone:612-798-8330
Practice Address - Fax:612-861-1533
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN683S6NEOtherBLUE CROSS BLUE SHIELD