Basic Information
| Provider Information | |||||||||
| NPI: | 1083096465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGPCNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 E COUNTY LINE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178852860 | ||||||||
| FaxNumber: | 3178852869 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 E COUNTY LINE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178852860 | ||||||||
| FaxNumber: | 3178852869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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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 | 363LG0600X | 71005840A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 71005840A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 201331220 | 05 | IN | MEDICAID |