Healthcare Provider Details

I. General information

NPI: 1548333206
Provider Name (Legal Business Name): JACQUELINE LEE NELSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BLACK COAL DR
FORT WASHAKIE WY
82514-0128
US

IV. Provider business mailing address

29 BLACK COAL DR
FORT WASHAKIE WY
82514-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7300
  • Fax: 307-332-7464
Mailing address:
  • Phone: 307-332-7300
  • Fax: 307-332-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4681A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: