Provider Demographics
NPI:1992336770
Name:NELSON, AMANDA NICOLE (COSMETIC THERAPIST)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:COSMETIC THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5137
Mailing Address - Country:US
Mailing Address - Phone:440-487-8493
Mailing Address - Fax:
Practice Address - Street 1:133 UP MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024
Practice Address - Country:US
Practice Address - Phone:440-487-8493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH32019195247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other