Provider Demographics
NPI:1699187005
Name:NELSON, LEEANN ANSICA (MD)
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:ANSICA
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 FIVAY RD STE 340
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7181
Mailing Address - Country:US
Mailing Address - Phone:728-861-0237
Mailing Address - Fax:
Practice Address - Street 1:14100 FIVAY RD STE 340
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7181
Practice Address - Country:US
Practice Address - Phone:727-861-0237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD.36842MD207R00000X
FLME136488207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC368426Medicaid
SC368426Medicaid
SCSC9473F694Medicare PIN