Provider Demographics
NPI:1790334118
Name:NELSON, CODY LEVI (MSN, RN, PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:LEVI
Last Name:NELSON
Suffix:
Gender:M
Credentials:MSN, RN, PMHNP-BC
Other - Prefix:
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Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1116 N 16TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2119
Practice Address - Country:US
Practice Address - Phone:765-423-6300
Practice Address - Fax:765-423-6301
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN28229694A363L00000X
IN71010196A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28229694AOtherSTATE OF INDIANA NURSING BOARD
IN71010195AOtherSTATE OF INDIANA NURSING BOARD - APRN PRESCRIPTIVE AUTHORITY
IN71010195BOtherSTATE OF INDIANA NURSING BOARD - CSR PRESCRIPTIVE AUTHORITY