Provider Demographics
NPI:1922744549
Name:NELSON, ANNIE NORWEDA (REV)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:NORWEDA
Last Name:NELSON
Suffix:
Gender:F
Credentials:REV
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REVEREND
Mailing Address - Street 1:9250 BRUCKHAUS ST APT 211
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4412
Mailing Address - Country:US
Mailing Address - Phone:540-259-2978
Mailing Address - Fax:
Practice Address - Street 1:9250 BRUCKHAUS ST APT 211
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4412
Practice Address - Country:US
Practice Address - Phone:540-259-2978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2209101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral