Healthcare Provider Details

I. General information

NPI: 1790764603
Provider Name (Legal Business Name): YVONNE SUE NELSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 10/01/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28650 STATE HIGHWAY 23
STAMFORD NY
12167-1712
US

IV. Provider business mailing address

28650 STATE HIGHWAY 23
STAMFORD NY
12167-1712
US

V. Phone/Fax

Practice location:
  • Phone: 607-652-2537
  • Fax: 607-652-2719
Mailing address:
  • Phone: 607-652-2537
  • Fax: 607-652-2719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number28675
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28675
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: