Provider Demographics
NPI:1639706559
Name:NELSON, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:485 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-5091
Mailing Address - Country:US
Mailing Address - Phone:617-972-5570
Mailing Address - Fax:617-972-5593
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5570
Practice Address - Fax:617-972-5593
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1014313208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics