Provider Demographics
NPI:1538443072
Name:NELSON, BETSY L (FNP)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:L
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-838-5702
Mailing Address - Fax:314-839-5596
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:STE C-1330
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-838-5702
Practice Address - Fax:314-839-5596
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016007907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO124510115Medicare PIN