Provider Demographics
NPI:1407259450
Name:NILSEN, ELLYN (DPT)
Entity Type:Individual
Prefix:
First Name:ELLYN
Middle Name:
Last Name:NILSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1181 AQUIDNECK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5255
Mailing Address - Country:US
Mailing Address - Phone:401-845-0840
Mailing Address - Fax:401-619-3752
Practice Address - Street 1:1181 AQUIDNECK AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5255
Practice Address - Country:US
Practice Address - Phone:401-845-0840
Practice Address - Fax:401-619-3752
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPT02748OtherSTATE LIC