Provider Demographics
NPI:1811682255
Name:NELSON, TERESA LYNN (DTR, CD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:DTR, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 N MEADE ST BLDG DOOR38
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3454
Mailing Address - Country:US
Mailing Address - Phone:920-454-1877
Mailing Address - Fax:
Practice Address - Street 1:1818 N MEADE ST BLDG DOOR38
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-454-1877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI887456136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered