Provider Demographics
NPI:1336572841
Name:NELSON, NICKLITA TAMICA
Entity Type:Individual
Prefix:MS
First Name:NICKLITA
Middle Name:TAMICA
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 1:11841 199TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3429
Mailing Address - Country:US
Mailing Address - Phone:929-257-7039
Mailing Address - Fax:
Practice Address - Street 1:2052 TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1560
Practice Address - Country:US
Practice Address - Phone:718-671-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404548363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health