Provider Demographics
NPI:1417213489
Name:NELSON, VICKI R (MD, PHD)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:R
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6328
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4296
Practice Address - Country:US
Practice Address - Phone:864-455-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.126659207Q00000X
SC39824207Q00000X
SCLL39824390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program