Provider Demographics
NPI:1326258765
Name:KYSELA, NANCY RUTH (PT)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:RUTH
Last Name:KYSELA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-6032
Mailing Address - Country:US
Mailing Address - Phone:904-534-0433
Mailing Address - Fax:
Practice Address - Street 1:4075 A1A S
Practice Address - Street 2:SUITE 105
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6773
Practice Address - Country:US
Practice Address - Phone:904-471-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY051AOtherBCBS NON-PARTICIPATING #