Provider Demographics
NPI:1942839634
Name:NELSON, COURTNEY ROSE MARIE (NP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ROSE MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8063
Mailing Address - Country:US
Mailing Address - Phone:860-679-8080
Mailing Address - Fax:860-679-1340
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-8063
Practice Address - Country:US
Practice Address - Phone:860-679-8080
Practice Address - Fax:860-679-1340
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-04
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ267253363L00000X
NM61340363L00000X
SC26654363LA2100X
CT11686363LA2100X
NV828148363LA2100X
NJ26NJ14859400363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid