Provider Demographics
NPI:1174934590
Name:NELSON, DANIEL KENNETH
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:KENNETH
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 HIGHWAY 98 E STE B
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-9452
Mailing Address - Country:US
Mailing Address - Phone:601-684-8800
Mailing Address - Fax:601-684-8008
Practice Address - Street 1:1097 HIGHWAY 98 E STE B
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-9452
Practice Address - Country:US
Practice Address - Phone:601-684-8800
Practice Address - Fax:601-684-8008
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor