Basic Information
| Provider Information | |||||||||
| NPI: | 1821246992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MAURENELLA | ||||||||
| MiddleName: | ANTIONETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | ANNETTE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 ROBERTS DRIVE | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703679732 | ||||||||
| FaxNumber: | 8704606133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1127 SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE VILLAGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702653808 | ||||||||
| FaxNumber: | 8702652733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.