Provider Demographics
NPI:1881567436
Name:NEILSON, TAMARA PATRICE (PHMNP)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:PATRICE
Last Name:NEILSON
Suffix:
Gender:F
Credentials:PHMNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 ALDEA DR
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-6949
Mailing Address - Country:US
Mailing Address - Phone:772-646-8618
Mailing Address - Fax:
Practice Address - Street 1:3425 BAYSIDE LAKES BLVD SE STE 103
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6867
Practice Address - Country:US
Practice Address - Phone:321-353-8763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11042384363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health