Basic Information
| Provider Information | |||||||||
| NPI: | 1467595330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | DUNEDIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346986615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277344551 | ||||||||
| FaxNumber: | 7277368648 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | DUNEDIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346986615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277344551 | ||||||||
| FaxNumber: | 7277368648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 562820 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | APRN9472905 | 01 | FL | LICENSE | OTHER | 562820 | 01 | CA | LICENSE | OTHER | 201832 | 01 | NC | STATE LICENSE | OTHER |