Provider Demographics
NPI:1114093069
Name:NELSON, CAROL LYNNE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LYNNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17876 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2602
Mailing Address - Country:US
Mailing Address - Phone:216-645-5539
Mailing Address - Fax:216-298-0241
Practice Address - Street 1:17876 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:216-645-5539
Practice Address - Fax:216-298-0241
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02175208Medicaid
NYP11668Medicare UPIN
NYCC6232Medicare ID - Type Unspecified