Provider Demographics
NPI:1558559088
Name:NELSON, THEA MARIE
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:MARIE
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 1:9465 IRVING AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-2932
Mailing Address - Country:US
Mailing Address - Phone:763-657-0037
Mailing Address - Fax:763-862-7438
Practice Address - Street 1:1013 111TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4519
Practice Address - Country:US
Practice Address - Phone:763-245-3643
Practice Address - Fax:763-862-7438
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL-038481-0164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse