Healthcare Provider Details

I. General information

NPI: 1114816550
Provider Name (Legal Business Name): ABBY NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 SE TIFFANY AVE STE 301
PORT ST LUCIE FL
34952-7567
US

IV. Provider business mailing address

708 HILLCREST DR
BRANDENBURG KY
40108-1424
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-8499
  • Fax: 772-335-8499
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: