Provider Demographics
NPI:1922360767
Name:NELSON, MARY JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4643 CAMP COLEMAN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-2821
Mailing Address - Country:US
Mailing Address - Phone:205-655-0603
Mailing Address - Fax:205-655-0693
Practice Address - Street 1:4643 CAMP COLEMAN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2821
Practice Address - Country:US
Practice Address - Phone:205-655-0603
Practice Address - Fax:205-655-0693
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL4314208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics