Provider Demographics
NPI:1922302140
Name:NELSON, DAVID ENOCH SR (NP-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ENOCH
Last Name:NELSON
Suffix:SR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 N RACINE AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1644
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:4900 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4605
Practice Address - Country:US
Practice Address - Phone:219-237-5170
Practice Address - Fax:219-321-1931
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28149900A363LF0000X
IL041330644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily