Provider Demographics
NPI:1497322416
Name:NELSON, MIKAELA (CO)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 CREEKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8410
Mailing Address - Country:US
Mailing Address - Phone:919-797-1230
Mailing Address - Fax:919-797-1240
Practice Address - Street 1:4702 CREEKSTONE DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8410
Practice Address - Country:US
Practice Address - Phone:919-797-1230
Practice Address - Fax:919-797-1240
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCO006354222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist