Provider Demographics
NPI:1053886457
Name:NELSON, STEPHANIE M (LAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:1649 N HOWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3253
Mailing Address - Country:US
Mailing Address - Phone:520-440-7487
Mailing Address - Fax:
Practice Address - Street 1:2532 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4404
Practice Address - Country:US
Practice Address - Phone:520-440-7487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ171100000X
AZLAC-000731171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty