Provider Demographics
NPI:1669979621
Name:NELSON, DANAE (DO)
Entity type:Individual
Prefix:
First Name:DANAE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4137 N 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5459
Mailing Address - Country:US
Mailing Address - Phone:623-877-7337
Mailing Address - Fax:623-772-0686
Practice Address - Street 1:15264 W BROOKSIDE LN STE 155
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3997
Practice Address - Country:US
Practice Address - Phone:623-877-7337
Practice Address - Fax:623-772-0686
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ009185208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program