Provider Demographics
NPI:1326533050
Name:NELLUMS, ROCHELLE ANTIONETTE (PTA)
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:ANTIONETTE
Last Name:NELLUMS
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 1:749 N ROHDE AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1109
Mailing Address - Country:US
Mailing Address - Phone:708-415-0736
Mailing Address - Fax:
Practice Address - Street 1:215 55TH ST
Practice Address - Street 2:
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-1578
Practice Address - Country:US
Practice Address - Phone:630-468-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004242225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant