Provider Demographics
NPI:1821241068
Name:NELSON, LIXON
Entity Type:Individual
Prefix:
First Name:LIXON
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 NW 122ND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-4517
Mailing Address - Country:US
Mailing Address - Phone:305-757-3372
Mailing Address - Fax:305-757-3352
Practice Address - Street 1:135 NW 122ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168
Practice Address - Country:US
Practice Address - Phone:305-757-3372
Practice Address - Fax:305-757-3352
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693274696Medicaid
FL693274698Medicaid