Provider Demographics
NPI:1558076091
Name:NELSON, AMBER (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 RB
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602-2118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 RB
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602-2118
Practice Address - Country:US
Practice Address - Phone:801-422-1958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11878700-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer