Provider Demographics
NPI:1568195733
Name:NELSON, CHARLA JEAN
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:JEAN
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 1:201 CRESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1462
Mailing Address - Country:US
Mailing Address - Phone:606-571-1732
Mailing Address - Fax:
Practice Address - Street 1:332 15TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7626
Practice Address - Country:US
Practice Address - Phone:606-420-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1110597163W00000X
OH354822163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse