Provider Demographics
NPI:1669643706
Name:NELSON, MICHELLE LEA (RPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEA
Last Name:NELSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 VERMILLION ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:SD
Mailing Address - Zip Code:57014-2168
Mailing Address - Country:US
Mailing Address - Phone:605-563-2251
Mailing Address - Fax:605-563-2250
Practice Address - Street 1:500 VERMILLION ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:SD
Practice Address - Zip Code:57014-2168
Practice Address - Country:US
Practice Address - Phone:605-563-2251
Practice Address - Fax:605-563-2250
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2018208100000X
IA03268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation