Provider Demographics
NPI:1164409587
Name:NELSON, JENNIFER L (APRN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-7325
Mailing Address - Fax:
Practice Address - Street 1:220 MAIN ST STE 1A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:CT
Practice Address - Zip Code:06478-1065
Practice Address - Country:US
Practice Address - Phone:203-888-5527
Practice Address - Fax:203-888-3727
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3304363LA2200X, 163W00000X
CT003304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53191Medicare UPIN
500001553Medicare ID - Type Unspecified