Provider Demographics
NPI:1740557701
Name:NELSON, CONNIE M (RPH)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0884
Mailing Address - Country:US
Mailing Address - Phone:608-754-2278
Mailing Address - Fax:
Practice Address - Street 1:1717 MILTON AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0884
Practice Address - Country:US
Practice Address - Phone:608-754-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist