1528441243 NPI number — KRISTA WERT NELSON PA, MPH

Table of content: KRISTA WERT NELSON PA, MPH (NPI 1528441243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528441243 NPI number — KRISTA WERT NELSON PA, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
KRISTA
Provider Middle Name:
WERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA, MPH
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:
1528441243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 S FISKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-434-1401
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 HICKORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-434-1401
Provider Business Practice Location Address Fax Number:
321-434-1667
Provider Enumeration Date:
06/30/2015

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: 363AS0400X , with the licence number:  PA9108801 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9108801 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 015511600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IG696Y . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 015511600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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