Provider Demographics
NPI:1275776957
Name:NISSLY, MICHELLE MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:NISSLY
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 1:1380 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-4642
Mailing Address - Country:US
Mailing Address - Phone:717-391-6430
Mailing Address - Fax:
Practice Address - Street 1:1380 ELM AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-4642
Practice Address - Country:US
Practice Address - Phone:717-391-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000938225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant