Healthcare Provider Details

I. General information

NPI: 1275163818
Provider Name (Legal Business Name): PATRICIA LYNN NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9990 COUNTY FARM RD STE 5
RIVERSIDE CA
92503-3542
US

IV. Provider business mailing address

9990 COUNTY FARM RD STE 5
RIVERSIDE CA
92503-3542
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4500
  • Fax:
Mailing address:
  • Phone: 951-358-4834
  • Fax: 951-358-3548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95066118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: