Basic Information
| Provider Information | |||||||||
| NPI: | 1740762947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAHOOD | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 828 W MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043209897 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2511 OLD CORNWALLIS RD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277131869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199325700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2018 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5010934 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.