Basic Information
| Provider Information | |||||||||
| NPI: | 1164409587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037327325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 MAIN ST STE 1A | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064781065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038885527 | ||||||||
| FaxNumber: | 2038883727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 3304 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | 3304 | CT | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 003304 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.