Basic Information
| Provider Information | |||||||||
| NPI: | 1588625107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156434340 | ||||||||
| FaxNumber: | 5156432784 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 E UNIVERSITY AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PLEASANT HILL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503278457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156432600 | ||||||||
| FaxNumber: | 5156434733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/16/2009 | ||||||||
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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 | 363LP0200X | 121268 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | R 089542-2 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 641042100 | 05 | MN | MEDICAID |