MEDICARE: CAROLINE NELSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1720793359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINE NELSON

Provider Business Mailing Address
First Line	:	2191 S MCCLELLAND ST APT 737
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4565
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2191 S MCCLELLAND ST APT 737
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4565
Country	:	US
Telephone Number	:	919-353-7116
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	01/18/2023

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Directions to “ CAROLINE NELSON ” Practice Location

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