Provider Demographics
NPI:1316395973
Name:NELSON, ANGELIQUE (ATC)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6908
Mailing Address - Country:US
Mailing Address - Phone:843-641-8623
Mailing Address - Fax:
Practice Address - Street 1:1675 GARDEN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6908
Practice Address - Country:US
Practice Address - Phone:843-641-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL45042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer