Provider Demographics
NPI:1275959165
Name:NELSON, PAULINE
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:
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 1:24131 148TH AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24131 148TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3265
Practice Address - Country:US
Practice Address - Phone:718-600-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-15
Last Update Date:2014-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2566531164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse