Basic Information
| Provider Information | |||||||||
| NPI: | 1770580177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053284540 | ||||||||
| FaxNumber: | 6053284531 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 S PLUM ST | ||||||||
| Address2: | |||||||||
| City: | VERMILLION | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056249111 | ||||||||
| FaxNumber: | 6056246636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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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 | 363L00000X | CNP0371 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | CP000371 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 6824460 | 05 | SD | MEDICAID |