Provider Demographics
NPI:1639571227
Name:NELSON, NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8560
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3979
Practice Address - Country:US
Practice Address - Phone:207-907-1430
Practice Address - Fax:207-907-3508
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209.012256367500000X
MERNA173045367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
F400188669Medicare PIN