Provider Demographics
NPI:1689639924
Name:NELSON, CHARLA NEOMA (DPT)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:NEOMA
Last Name:NELSON
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 1:20261 E OCOTILLO RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-8806
Mailing Address - Country:US
Mailing Address - Phone:480-677-2771
Mailing Address - Fax:
Practice Address - Street 1:6505 SHILOH RD STE 100
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1645
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7761225100000X
MI5501012186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist