Provider Demographics
NPI:1972844850
Name:NELSEN, M'LISS DAWN
Entity Type:Individual
Prefix:
First Name:M'LISS
Middle Name:DAWN
Last Name:NELSEN
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 1:1700 E PALM VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-4677
Mailing Address - Country:US
Mailing Address - Phone:512-255-0617
Mailing Address - Fax:512-238-7637
Practice Address - Street 1:1700 E PALM VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4677
Practice Address - Country:US
Practice Address - Phone:512-255-0617
Practice Address - Fax:512-238-7637
Is Sole Proprietor?:No
Enumeration Date:2013-03-02
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist