Basic Information
| Provider Information | |||||||||
| NPI: | 1184787681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | DEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN., CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | MARCIA | ||||||||
| OtherMiddleName: | DEE | ||||||||
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| OtherCredential: | RN, CNM | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1204 GARNER ST | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759614278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097898258 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 JACOB STREET | ||||||||
| Address2: | |||||||||
| City: | TIMPSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759755028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9362543338 | ||||||||
| FaxNumber: | 9362543339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 251633 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 133241308 | 05 | TX | MEDICAID |