Provider Demographics
NPI:1548849102
Name:NELLESSEN, NATHAN JACK
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JACK
Last Name:NELLESSEN
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 1:11234 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:909-558-6491
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-6491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAA1801882083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program