Provider Demographics
NPI:1831316637
Name:NELSON, MICHELLE RENA (DC)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENA
Last Name:NELSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1301
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74818-1301
Mailing Address - Country:US
Mailing Address - Phone:405-382-3635
Mailing Address - Fax:405-382-1037
Practice Address - Street 1:1117 N MILT PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2321
Practice Address - Country:US
Practice Address - Phone:405-382-3635
Practice Address - Fax:405-382-1037
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU69798Medicare UPIN