Basic Information
| Provider Information | |||||||||
| NPI: | 1316438757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 244 | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498710244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063612293 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2292 US HIGHWAY 41 W STE 6 | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062284204 | ||||||||
| FaxNumber: | 8552612633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2018 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 4703100821 | MI | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.