Provider Demographics
NPI:1922858091
Name:NELSON, COURTENEY GENIECE
Entity type:Individual
Prefix:
First Name:COURTENEY GENIECE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6033
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-0033
Mailing Address - Country:US
Mailing Address - Phone:916-779-9212
Mailing Address - Fax:
Practice Address - Street 1:112 S ALLEN ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2205
Practice Address - Country:US
Practice Address - Phone:916-779-9212
Practice Address - Fax:916-779-9212
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51139704171000000X
374K00000X, 376J00000X, 390200000X, 376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No376J00000XNursing Service Related ProvidersHomemaker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYFP69081HMedicaid