Provider Demographics
NPI:1245041516
Name:NELSON, BRIAN TANNER (HIS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:TANNER
Last Name:NELSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-4205
Mailing Address - Country:US
Mailing Address - Phone:352-314-8805
Mailing Address - Fax:407-650-3065
Practice Address - Street 1:713 N 14TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4205
Practice Address - Country:US
Practice Address - Phone:352-314-8805
Practice Address - Fax:407-650-3065
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5859237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist