Provider Demographics
NPI:1093724965
Name:NELISSEN, DEBRA JEAN (OD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:JEAN
Last Name:NELISSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:JEAN
Other - Last Name:MCNAMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:UNIT 33100
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-8476
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003292152W00000X, 152WV0400X
HIOD-810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist