Healthcare Provider Details

I. General information

NPI: 1598279077
Provider Name (Legal Business Name): MICHELE NIELSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

420 GREENWICH LN
MODESTO CA
95350-1581
US

V. Phone/Fax

Practice location:
  • Phone: 209-300-8800
  • Fax:
Mailing address:
  • Phone: 209-534-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number504014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: