Healthcare Provider Details

I. General information

NPI: 1396016093
Provider Name (Legal Business Name): MARIE ELLEN NIELSEN MS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 01/04/2026
Certification Date: 01/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E CITRUS AVE STE A
REDLANDS CA
92374-4802
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-389-1304
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: