=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407274293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MI NELSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2014
-----------------------------------------------------
Last Update Date | 11/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4622 PROGRESS DR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52807-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-742-5800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4622 PROGRESS DR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52807-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036.147610
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD-45699
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------