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General NPI Number Information
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NPI Number | 1477354967
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Entity Type | Individual
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Provider Name | MAKENNA PEARL NELSON
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Gender |
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Dates
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Enumeration Date | 03/21/2025
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Last Update Date | 04/11/2025
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Provider Practice Location Address
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Address Line | 1601 GOLF COURSE RD
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-8648
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Country | US
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Telephone | 218-326-3401
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Fax |
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Provider Business Mailing Address
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Address Line | 19624 BROOK PARK RD
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City | PINE CITY
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State | MN
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Zip | 55063-6030
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Country | US
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Telephone |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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