Provider Demographics
NPI:1457942229
Name:NELSON, NADINE AVE
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:AVE
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 1:5761 WELLS CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6007
Mailing Address - Country:US
Mailing Address - Phone:470-782-2371
Mailing Address - Fax:
Practice Address - Street 1:5761 WELLS CIRCLE
Practice Address - Street 2:PRVT
Practice Address - City:STONE MTN
Practice Address - State:GA
Practice Address - Zip Code:30087-3008
Practice Address - Country:US
Practice Address - Phone:470-782-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALMT007938225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5520Medicaid
NY5520Medicaid