Provider Demographics
NPI:1174878128
Name:NELSON, DEDRA TAREE (HOME HEALTH)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:TAREE
Last Name:NELSON
Suffix:
Gender:F
Credentials:HOME HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 15TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-5013
Mailing Address - Country:US
Mailing Address - Phone:262-721-8567
Mailing Address - Fax:
Practice Address - Street 1:2808 15TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-5013
Practice Address - Country:US
Practice Address - Phone:262-721-8567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide