Provider Demographics
NPI:1720733942
Name:NELSON, CHRISTINE ALICIA
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ALICIA
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14619 DECOY LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0413
Mailing Address - Country:US
Mailing Address - Phone:909-743-1809
Mailing Address - Fax:
Practice Address - Street 1:1060 E FOOTHILL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4070
Practice Address - Country:US
Practice Address - Phone:909-981-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily