Healthcare Provider Details

I. General information

NPI: 1497322416
Provider Name (Legal Business Name): MIKAELA NELSON CO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 CREEKSTONE DR
DURHAM NC
27703-8410
US

IV. Provider business mailing address

4702 CREEKSTONE DR
DURHAM NC
27703-8410
US

V. Phone/Fax

Practice location:
  • Phone: 919-797-1230
  • Fax: 919-797-1240
Mailing address:
  • Phone: 919-797-1230
  • Fax: 919-797-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCO006354
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: