Healthcare Provider Details

I. General information

NPI: 1376945055
Provider Name (Legal Business Name): VANESSA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S HIGH ST
ANTLERS OK
74523-3818
US

IV. Provider business mailing address

411 S CENTRAL AVE
IDABEL OK
74745-6059
US

V. Phone/Fax

Practice location:
  • Phone: 580-298-2830
  • Fax: 580-298-6723
Mailing address:
  • Phone: 580-286-5045
  • Fax: 580-286-5721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: