Provider Demographics
NPI:1659491207
Name:NELSON, PHYLLIS ANN (RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CLASSIC CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:76082-7281
Mailing Address - Country:US
Mailing Address - Phone:817-444-8743
Mailing Address - Fax:817-270-1369
Practice Address - Street 1:108 DENVER TRAIL
Practice Address - Street 2:HARRIS METHODIST NORTHWEST HOSPITAL
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020
Practice Address - Country:US
Practice Address - Phone:817-444-8743
Practice Address - Fax:817-270-1369
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02276133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered