Provider Demographics
NPI:1093082836
Name:NUSBAUM, KYLEE (PTA)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 MESQUITE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5777
Mailing Address - Country:US
Mailing Address - Phone:928-854-4776
Mailing Address - Fax:
Practice Address - Street 1:1948 MESQUITE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5777
Practice Address - Country:US
Practice Address - Phone:928-854-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9592225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant