Healthcare Provider Details

I. General information

NPI: 1962628479
Provider Name (Legal Business Name): ANDREA NIELSEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD STE 555
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-2020
  • Fax: 248-551-2267
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003103
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: