Provider Demographics
NPI:1770055865
Name:NELSON, AJA SHANAE (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:AJA
Middle Name:SHANAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 WESTERDALE DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9525 WESTERDALE DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-2440
Practice Address - Country:US
Practice Address - Phone:240-355-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4257811744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management