Provider Demographics
NPI:1770717357
Name:NELSON, VERNICE NICOLE (RN)
Entity type:Individual
Prefix:
First Name:VERNICE
Middle Name:NICOLE
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 1:1313 SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2345
Mailing Address - Country:US
Mailing Address - Phone:708-832-9908
Mailing Address - Fax:708-832-9935
Practice Address - Street 1:1313 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2345
Practice Address - Country:US
Practice Address - Phone:708-832-9908
Practice Address - Fax:708-832-9935
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010797251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-8040Medicare PIN