Provider Demographics
NPI:1962858837
Name:NELSON, MARLO
Entity Type:Individual
Prefix:MRS
First Name:MARLO
Middle Name:
Last Name:NELSON
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 1:919 CRANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1023
Mailing Address - Country:US
Mailing Address - Phone:646-228-4407
Mailing Address - Fax:
Practice Address - Street 1:919 CRANFORD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1023
Practice Address - Country:US
Practice Address - Phone:646-228-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295030-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse