Basic Information
| Provider Information | |||||||||
| NPI: | 1720545031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | LYNN | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9051 FLORIDA MINING BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336341240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133742070 | ||||||||
| FaxNumber: | 8133370937 | ||||||||
| Practice Location | |||||||||
| Address1: | 7333 INTERNATIONAL PL | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342408418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437427937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2019 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | RBT-19-79149 | FL | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106S00000X | RBT-19-79149 | FL | Y |
No ID Information.