MEDICARE: SAMANTHA JO NELSON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	32730531	WI
2	163W00000X	Registered Nurse	110341830	WI

General Provider Information

NPI Number	:	1538802079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JO NELSON RN

Provider Business Mailing Address
First Line	:	2240 SOUTH RD
Second Line	:
City	:	KRONENWETTER
State	:	WI
Zip	:	54455-9616
Country	:	US
Telephone Number	:	715-351-8937
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 SOUTH RD
Second Line	:
City	:	KRONENWETTER
State	:	WI
Zip	:	54455-9616
Country	:	US
Telephone Number	:	715-351-8937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2022
Last Update Date	:	03/08/2023

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