Provider Demographics
NPI:1942839634
Name:NELSON, COURTNEY ROSE MARIE (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ROSE MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD STE 580
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4281
Practice Address - Country:US
Practice Address - Phone:864-455-7874
Practice Address - Fax:864-455-8933
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-04
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM61340363L00000X
NV828148363LA2100X
AZ267253363L00000X
SC26654363LA2100X
CT11686363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid