Healthcare Provider Details

I. General information

NPI: 1699289975
Provider Name (Legal Business Name): TOSHA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2017
Last Update Date: 06/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409
US

IV. Provider business mailing address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-2101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN144039
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP11488
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: