Provider Demographics
NPI:1659855013
Name:NELSON, MIRANDA JAYNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JAYNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1012
Mailing Address - Country:US
Mailing Address - Phone:989-463-5876
Mailing Address - Fax:989-466-5956
Practice Address - Street 1:200 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801
Practice Address - Country:US
Practice Address - Phone:989-463-5876
Practice Address - Fax:989-466-5956
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289629363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily