Provider Demographics
NPI:1396016093
Name:NIELSEN, MARIE ELLEN (MS, PA-C)
Entity type:Individual
Prefix:MISS
First Name:MARIE
Middle Name:ELLEN
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E CITRUS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4802
Mailing Address - Country:US
Mailing Address - Phone:909-794-3682
Mailing Address - Fax:909-389-1323
Practice Address - Street 1:1600 E CITRUS AVE STE A
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4802
Practice Address - Country:US
Practice Address - Phone:909-389-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18155OtherMEDICAL LICENSE
CAPENDINGOtherMEDICARE