Provider Demographics
NPI:1659645299
Name:NELSON, MARIESA LYNN (CSFA)
Entity Type:Individual
Prefix:MRS
First Name:MARIESA
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N ORANGE ST
Mailing Address - Street 2:SUITE #106
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2998
Mailing Address - Country:US
Mailing Address - Phone:406-542-7300
Mailing Address - Fax:406-542-0003
Practice Address - Street 1:900 N ORANGE ST
Practice Address - Street 2:SUITE #106
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2998
Practice Address - Country:US
Practice Address - Phone:406-542-7300
Practice Address - Fax:406-542-0003
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT131878246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist