Healthcare Provider Details

I. General information

NPI: 1417557638
Provider Name (Legal Business Name): BRENDA L NELSON-PORTER ND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WILSON CIR
NEWNAN GA
30263-5594
US

IV. Provider business mailing address

105 WILSON CIR
NEWNAN GA
30263-5594
US

V. Phone/Fax

Practice location:
  • Phone: 770-365-7577
  • Fax:
Mailing address:
  • Phone: 770-365-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QG0250X
TaxonomyGenetics Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code291900000X
TaxonomyMilitary Clinical Medical Laboratory
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: