Provider Demographics
NPI:1821370032
Name:NELSON, MICHELLE R
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:ROBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7500 HENNESSY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4339
Mailing Address - Country:US
Mailing Address - Phone:225-768-1777
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD STE 612
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4366
Practice Address - Country:US
Practice Address - Phone:225-769-5656
Practice Address - Fax:225-766-6996
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2316206Medicaid
352349YJA2Medicare PIN