MEDICARE: MISS BREANNA NELSON MS/EDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	SS1496	FL

General Provider Information

NPI Number	:	1174109813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS BREANNA NELSON MS/EDS

Provider Business Mailing Address
First Line	:	1603 PALM LEAF DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33510-2038
Country	:	US
Telephone Number	:	321-243-3689
Fax Number	:

Provider Business Practice Location Address
First Line	:	1603 PALM LEAF DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33510-2038
Country	:	US
Telephone Number	:	321-243-3689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2021
Last Update Date	:	03/23/2021

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