Healthcare Provider Details

I. General information

NPI: 1093724965
Provider Name (Legal Business Name): DEBRA JEAN NELISSEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEBRA JEAN MCNAMARA O.D.

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100
APO AE
09180-3100
US

IV. Provider business mailing address

UNIT 33100
APO AE
09180-3100
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-8476
  • Fax:
Mailing address:
  • Phone: 314-590-8476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0003292
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD-810
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPT.0003292
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: