Healthcare Provider Details

I. General information

NPI: 1447874060
Provider Name (Legal Business Name): KRISTIN NELSON OD, IACMM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11390 SUMMERLIN SQUARE DR
FORT MYERS BEACH FL
33931-5300
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-8880
  • Fax: 239-343-4213
Mailing address:
  • Phone: 239-343-8880
  • Fax: 239-343-4213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number0466011423
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046011423
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6206
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011423
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: