Provider Demographics
NPI:1629344213
Name:NELSON, ANDREA (LPC, RN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3877
Mailing Address - Country:US
Mailing Address - Phone:815-387-5681
Mailing Address - Fax:815-391-5041
Practice Address - Street 1:3815 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-7631
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:815-391-5040
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.006392101YP2500X
IL041.176095163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional