Provider Demographics
NPI:1164712014
Name:NELSON, CATHERINE EM
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:EM
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3116
Mailing Address - Country:US
Mailing Address - Phone:920-877-3102
Mailing Address - Fax:920-855-8790
Practice Address - Street 1:130 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3116
Practice Address - Country:US
Practice Address - Phone:920-877-3102
Practice Address - Fax:920-855-8790
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60067-021207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1164712014Medicaid
WIK400270380Medicare PIN