Provider Demographics
NPI:1831324342
Name:NELSON, KRISTA NICOLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:NICOLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5139 MATTIS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2250
Mailing Address - Country:US
Mailing Address - Phone:314-909-1920
Mailing Address - Fax:314-909-1980
Practice Address - Street 1:235 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025
Practice Address - Country:US
Practice Address - Phone:618-307-9015
Practice Address - Fax:618-307-9017
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005540213ES0103X
MO2012023303213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery