Provider Demographics
NPI:1295328078
Name:NELSON, KATHRYN CHRISTIANA
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CHRISTIANA
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 1:9136 S REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-8813
Mailing Address - Country:US
Mailing Address - Phone:231-590-6865
Mailing Address - Fax:
Practice Address - Street 1:194 N DIVISION AVE
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421-7500
Practice Address - Country:US
Practice Address - Phone:231-854-6605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist