Healthcare Provider Details

I. General information

NPI: 1922744549
Provider Name (Legal Business Name): ANNIE NORWEDA NELSON REV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNIE NELSON REVEREND

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 BRUCKHAUS ST APT 211
RALEIGH NC
27617-4412
US

IV. Provider business mailing address

9250 BRUCKHAUS ST APT 211
RALEIGH NC
27617-4412
US

V. Phone/Fax

Practice location:
  • Phone: 540-259-2978
  • Fax:
Mailing address:
  • Phone: 540-259-2978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number2209
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: