MEDICARE: MRS. LAURA B NILSEN EDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	SS848	FL

General Provider Information

NPI Number	:	1871930230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA B NILSEN EDS

Provider Business Mailing Address
First Line	:	2172 BRIGHTON BAY TRL W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-7205
Country	:	US
Telephone Number	:	904-476-5916
Fax Number	:

Provider Business Practice Location Address
First Line	:	4745 SUTTON PARK CT
Second Line	:	SUITE 802
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-0250
Country	:	US
Telephone Number	:	904-476-5916
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2013
Last Update Date	:	05/25/2013

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