Provider Demographics
NPI:1619524352
Name:NELSON, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
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 1:3350 42ND ST S APT 110
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6950
Mailing Address - Country:US
Mailing Address - Phone:701-799-0190
Mailing Address - Fax:
Practice Address - Street 1:3350 42ND ST S APT 110
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6950
Practice Address - Country:US
Practice Address - Phone:701-799-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider