Provider Demographics
NPI:1720177702
Name:NELSON, RENEE LUCILLE (RN)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:LUCILLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 FALLSTAFF RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8067
Mailing Address - Country:US
Mailing Address - Phone:803-699-6208
Mailing Address - Fax:
Practice Address - Street 1:4500 STUART ST
Practice Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301863163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVAD 000Medicare UPIN