Healthcare Provider Details

I. General information

NPI: 1629060850
Provider Name (Legal Business Name): MARIE NELSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CENTENNIAL PKWY
CAMERON NC
28326-4013
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-908-6257
  • Fax: 910-436-2540
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200101127
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89130XX
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: