Provider Demographics
NPI:1043783871
Name:NELSON, KYLE R
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 RIVER ROCK LN
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6850
Mailing Address - Country:US
Mailing Address - Phone:972-955-3089
Mailing Address - Fax:
Practice Address - Street 1:1621 COIT RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6141
Practice Address - Country:US
Practice Address - Phone:972-596-7930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140416225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1609397785Medicaid