Basic Information
| Provider Information | |||||||||
| NPI: | 1770977407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8906 SPANISH RIDGE AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891481319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023303102 | ||||||||
| FaxNumber: | 7029124994 | ||||||||
| Practice Location | |||||||||
| Address1: | 861 CORONADO CENTER DR STE 131 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7257770414 | ||||||||
| FaxNumber: | 7025655027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2015 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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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 | APRN001911 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1770977407 | 05 | NV | MEDICAID |