Provider Demographics
NPI:1790895407
Name:NELSON, MARTHA A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:NELSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1152
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-1152
Mailing Address - Country:US
Mailing Address - Phone:802-649-3604
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-0001
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:802-291-6289
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010009829363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT48287OtherBCBSVT