Provider Demographics
NPI:1598241333
Name:NELSON, MICHELE LEA
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEA
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 1:615 WILTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6128
Mailing Address - Country:US
Mailing Address - Phone:207-778-5615
Mailing Address - Fax:207-778-5623
Practice Address - Street 1:615 WILTON RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6128
Practice Address - Country:US
Practice Address - Phone:207-778-5615
Practice Address - Fax:207-778-5623
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist