Provider Demographics
NPI:1679114805
Name:NELSON, PHYLLIS ADOLPHUS
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ADOLPHUS
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 1:362 E TROY ST UPPR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2851
Mailing Address - Country:US
Mailing Address - Phone:313-404-0761
Mailing Address - Fax:
Practice Address - Street 1:362 E TROY ST UPPR
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2851
Practice Address - Country:US
Practice Address - Phone:313-404-0761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704184714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine