Provider Demographics
NPI:1477889418
Name:NELSON, REBECCA ANN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
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 1:3785 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1653
Mailing Address - Country:US
Mailing Address - Phone:248-379-5188
Mailing Address - Fax:
Practice Address - Street 1:3601 W. THIRTEEN MILE ROAD
Practice Address - Street 2:EXT 84116 REBECCA NELSON
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-898-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF0809384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily