Provider Demographics
NPI:1649848524
Name:NELSON, AMANDA NATALIE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NATALIE
Last Name:NELSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10250 SANTA MONICA BLVD STE 2440
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-6593
Practice Address - Country:US
Practice Address - Phone:310-286-0122
Practice Address - Fax:310-286-0125
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA187564207Q00000X
GA102899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine