Basic Information
| Provider Information | |||||||||
| NPI: | 1073530515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELLES | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 CIVIC CENTER LN | ||||||||
| Address2: | ATTN: CANCER CENTER | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864035607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288540094 | ||||||||
| FaxNumber: | 9286808986 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DRIVE SOUTH | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R24684 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP8464 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R24684 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 116637 | 05 | AZ | MEDICAID | 1462407 | 05 | ND | MEDICAID | 19636 | 05 | ND | MEDICAID |