Provider Demographics
NPI:1205426798
Name:NELSON, ALEXIS JADE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JADE
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 1:3460 TAMBOUR DR
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-5368
Mailing Address - Country:US
Mailing Address - Phone:504-919-2424
Mailing Address - Fax:
Practice Address - Street 1:888 TERRY PKWY
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-5270
Practice Address - Country:US
Practice Address - Phone:504-582-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013950183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician