1679114805 NPI number — PHYLLIS ADOLPHUS NELSON PMHNP-C

Table of content: PHYLLIS ADOLPHUS NELSON PMHNP-C (NPI 1679114805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679114805 NPI number — PHYLLIS ADOLPHUS NELSON PMHNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
PHYLLIS
Provider Middle Name:
ADOLPHUS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679114805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1941 ORLEANS ST
Provider Second Line Business Mailing Address:
APT 632
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48207-2754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-907-4970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3281 COOLIDGE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKLEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48072-1633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-915-9138
Provider Business Practice Location Address Fax Number:
313-216-2776
Provider Enumeration Date:
09/29/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  4704184714 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 4704184714 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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