Provider Demographics
NPI:1114798519
Name:NELSON, AUGUSTINE (CHW/COMMUNITY HEALTH)
Entity Type:Individual
Prefix:MRS
First Name:AUGUSTINE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:CHW/COMMUNITY HEALTH
Other - Prefix:MRS
Other - First Name:AUGUSTINE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERTIFIED NURSE ASST
Mailing Address - Street 1:400 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24281 STEWART AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-5731
Practice Address - Country:US
Practice Address - Phone:313-448-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker