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General NPI Number Information
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NPI Number | 1164053385
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Entity Type | Individual
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Provider Name | ELAINE MARIE NELSON COSMETIC THERAPIST
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Gender | Female
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Dates
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Enumeration Date | 01/27/2020
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Last Update Date | 01/27/2020
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Provider Practice Location Address
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Address Line | COSMETIC LASER INC 8353 MENTOR AVE. UNIT 7
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City | MENTOR
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State | OH
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Zip | 44077
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Country | US
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Telephone | 440-477-4074
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Fax |
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Provider Business Mailing Address
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Address Line | 5822 WOODHILL ST
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City | PAINESVILLE
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State | OH
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Zip | 44077-5167
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Country | US
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Telephone | 440-477-4074
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | 32.012312
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License Number State | OH
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