MEDICARE: CRYSTAL D NELSON LPN

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	LP036472	AZ

General Provider Information

NPI Number	:	1861899791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL D NELSON LPN

Provider Business Mailing Address
First Line	:	9224 S LAS LOMITAS ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-7718
Country	:	US
Telephone Number	:	602-769-9629
Fax Number	:

Provider Business Practice Location Address
First Line	:	9224 S LAS LOMITAS ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-7718
Country	:	US
Telephone Number	:	602-769-9629
Fax Number	:

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

Provider Enumeration Date	:	11/20/2014
Last Update Date	:	11/20/2014

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