Healthcare Provider Details

I. General information

NPI: 1730901042
Provider Name (Legal Business Name): ANNA GABRIELLE NELSON MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

6146 CARVEL AVE
INDIANAPOLIS IN
46220-2039
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-5000
  • Fax:
Mailing address:
  • Phone: 219-380-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003934A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: