Provider Demographics
NPI:1164493243
Name:NELSON, JILL T (APRN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:T
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 1:421 COTTAGE GROVE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3119
Mailing Address - Country:US
Mailing Address - Phone:860-242-3393
Mailing Address - Fax:860-242-3301
Practice Address - Street 1:421 COTTAGE GROVE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3119
Practice Address - Country:US
Practice Address - Phone:860-242-3393
Practice Address - Fax:860-242-3301
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001331363LA2200X, 363L00000X
CT1331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT400001331CT04OtherANTHEM BLUE SHIELD
CT010331OtherCONNECTICARE
CT2V4369OtherHEALTHNET
CT004195039Medicaid
P000348883Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CT500001770Medicare ID - Type UnspecifiedMEDICARE
CT004195039Medicaid