Provider Demographics
NPI:1073650628
Name:NELSON, CHARLOTTE M (ANP)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6075
Mailing Address - Country:US
Mailing Address - Phone:907-373-6500
Mailing Address - Fax:888-456-0663
Practice Address - Street 1:4551 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6075
Practice Address - Country:US
Practice Address - Phone:907-373-6500
Practice Address - Fax:888-456-0663
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK857363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP4576Medicaid
AKNP4576Medicaid
AKK160566Medicare ID - Type UnspecifiedMEDICARE ID NUMBER