Provider Demographics
NPI:1033288360
Name:NELSON, COLLEEN (PT, MPT)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-8748
Mailing Address - Country:US
Mailing Address - Phone:660-888-5476
Mailing Address - Fax:
Practice Address - Street 1:3001 IVY DR
Practice Address - Street 2:
Practice Address - City:NORTH NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67117-8001
Practice Address - Country:US
Practice Address - Phone:316-284-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-010238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-010238OtherPROFESSIONAL LICENSE
MO2010024531OtherSTATE LICENSE
K39940Medicare PIN