Provider Demographics
NPI:1306293428
Name:NELSON, RENAE JEAN
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:JEAN
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 521833
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652-1833
Mailing Address - Country:US
Mailing Address - Phone:907-892-1628
Mailing Address - Fax:907-892-1629
Practice Address - Street 1:3498 SOUTH LAKEVIEW LOOP
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:AK
Practice Address - Zip Code:99652
Practice Address - Country:US
Practice Address - Phone:907-892-1628
Practice Address - Fax:907-892-1629
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK107490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist