Provider Demographics
NPI:1568456135
Name:NELSON, MARYALICE (ARNP)
Entity Type:Individual
Prefix:
First Name:MARYALICE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:MARYALICE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:884 SW 51ST WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3858
Mailing Address - Country:US
Mailing Address - Phone:352-374-2224
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:GU CLINIC
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-548-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1850332363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP02180Medicare UPIN