Provider Demographics
NPI:1275909590
Name:NELSON, KYLIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5956 E PIMA ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4375
Mailing Address - Country:US
Mailing Address - Phone:520-885-4636
Mailing Address - Fax:520-885-4736
Practice Address - Street 1:5956 E PIMA ST STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4375
Practice Address - Country:US
Practice Address - Phone:520-885-4636
Practice Address - Fax:520-885-4736
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11787OtherPHYICAL THERAPY LICENSE
AZ058785Medicaid