Healthcare Provider Details

I. General information

NPI: 1679560304
Provider Name (Legal Business Name): CONNIE MICHELLE NELSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 B ST
PLUMMER ID
83851
US

IV. Provider business mailing address

170 LARCH RD
ST MARIES ID
83861-7150
US

V. Phone/Fax

Practice location:
  • Phone: 208-686-1931
  • Fax: 208-686-1035
Mailing address:
  • Phone: 208-245-2116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberN25223
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: