Provider Demographics
NPI:1700867405
Name:NELSON, KATHIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHIE
Middle Name:ANN
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 1:1001 COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1617
Mailing Address - Country:US
Mailing Address - Phone:330-480-2616
Mailing Address - Fax:330-480-7979
Practice Address - Street 1:1001 COVINGTON ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1617
Practice Address - Country:US
Practice Address - Phone:330-480-2616
Practice Address - Fax:330-480-7979
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.069612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2035827Medicaid