Provider Demographics
NPI:1639410244
Name:NELSON, KRISTEN DAWN (RN, FNP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DAWN
Last Name:NELSON
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-332-8185
Mailing Address - Fax:805-332-8186
Practice Address - Street 1:1102 EAST CLARK AVENUE
Practice Address - Street 2:SUITE 120A
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5175
Practice Address - Country:US
Practice Address - Phone:805-332-8185
Practice Address - Fax:805-332-8186
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB247140OtherMEDICARE ID