Healthcare Provider Details

I. General information

NPI: 1619791886
Provider Name (Legal Business Name): ALICIA DAWN NELSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

4256 E STATE ROAD 54
BLOOMFIELD IN
47424-6015
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4102
  • Fax:
Mailing address:
  • Phone: 812-381-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28184759A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: