Provider Demographics
NPI:1265788251
Name:NELSON, MARLA N (FNP-C)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:N
Last Name:NELSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:MARLA
Other - Middle Name:N
Other - Last Name:SUTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:445 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653
Mailing Address - Country:US
Mailing Address - Phone:601-384-3720
Mailing Address - Fax:
Practice Address - Street 1:54 SERGEANT PRENTISS DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4726
Practice Address - Country:US
Practice Address - Phone:601-433-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN080053-AP06630363LF0000X
MSR823883363LF0000X
LAAP06630363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09332548Medicaid