Provider Demographics
NPI:1760546824
Name:NELSON, NACOLE
Entity Type:Individual
Prefix:
First Name:NACOLE
Middle Name:
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 1:9420 KINGSVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8571
Mailing Address - Country:US
Mailing Address - Phone:612-388-7511
Mailing Address - Fax:
Practice Address - Street 1:15300 GROVE CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4469
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR154126-7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500003673Medicare PIN