Healthcare Provider Details

I. General information

NPI: 1366861981
Provider Name (Legal Business Name): HEATHER D NIELSEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 06/05/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 VILLAGE COMMONS DRIVE
ST. AUGUSTINE FL
32092
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-1441
  • Fax: 904-390-7463
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS14698
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: