Provider Demographics
NPI:1063941268
Name:NELSON, PERSEPHONE (LPN)
Entity type:Individual
Prefix:
First Name:PERSEPHONE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 ASTON VILLA
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-9817
Mailing Address - Country:US
Mailing Address - Phone:585-802-7576
Mailing Address - Fax:
Practice Address - Street 1:37 ASTON VILLA
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-9817
Practice Address - Country:US
Practice Address - Phone:585-802-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2554841164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse