1073866174 NPI number — MS. SERENA COURTNEY NELSON LVN

Table of content: MS. SERENA COURTNEY NELSON LVN (NPI 1073866174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073866174 NPI number — MS. SERENA COURTNEY NELSON LVN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
SERENA
Provider Middle Name:
COURTNEY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LVN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073866174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11867
Provider Second Line Business Mailing Address:
CORRECTIONAL HEALTH DIVISION
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93775-1867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-600-3229
Provider Business Mailing Address Fax Number:
559-445-2772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 M ST
Provider Second Line Business Practice Location Address:
CORRECTIONAL HEALTH 2ND FLOOR
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93721-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-442-2404
Provider Business Practice Location Address Fax Number:
559-442-5277
Provider Enumeration Date:
10/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164X00000X , with the licence number:  267835 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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