Provider Demographics
NPI:1306834353
Name:NELSON, NANCY L (AUD, CCC-A)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-7002
Mailing Address - Country:US
Mailing Address - Phone:812-855-7439
Mailing Address - Fax:812-855-5561
Practice Address - Street 1:200 S JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7002
Practice Address - Country:US
Practice Address - Phone:812-855-7439
Practice Address - Fax:812-855-5561
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23001931231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200508550AMedicaid
IN200508550AMedicaid