Provider Demographics
NPI:1154866119
Name:NYSTROM, DEBORAH TUCKEY (LPT)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:TUCKEY
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 WEST I-20
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017
Mailing Address - Country:US
Mailing Address - Phone:817-466-7276
Mailing Address - Fax:817-466-7286
Practice Address - Street 1:2310 WEST I-20
Practice Address - Street 2:SUITE 204
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017
Practice Address - Country:US
Practice Address - Phone:817-466-7276
Practice Address - Fax:817-466-7286
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1035228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist