Provider Demographics
NPI:1760951438
Name:NIELSEN, TASHERA MURAY
Entity Type:Individual
Prefix:
First Name:TASHERA
Middle Name:MURAY
Last Name:NIELSEN
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 1:7925 MERRILL RD APT 2809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-6544
Mailing Address - Country:US
Mailing Address - Phone:904-536-4052
Mailing Address - Fax:
Practice Address - Street 1:7925 MERRILL RD APT 2809
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-6544
Practice Address - Country:US
Practice Address - Phone:904-536-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-24
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM102240-P171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-2548684OtherFEIN