Healthcare Provider Details

I. General information

NPI: 1720177702
Provider Name (Legal Business Name): RENEE LUCILLE NELSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 STUART ST MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS
FORT JACKSON SC
29207-5720
US

IV. Provider business mailing address

166 FALLSTAFF RD
COLUMBIA SC
29229-8067
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2618
  • Fax: 803-751-2689
Mailing address:
  • Phone: 803-699-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number301863
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: