Healthcare Provider Details

I. General information

NPI: 1902530637
Provider Name (Legal Business Name): ROBERT J NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 07/09/2022
Certification Date: 07/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 RISING SUN AVE
PHILADELPHIA PA
19140-5318
US

IV. Provider business mailing address

1140 RISING SUN AVE
PHILADELPHIA PA
19140-5318
US

V. Phone/Fax

Practice location:
  • Phone: 302-442-3270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: