Provider Demographics
NPI:1841747599
Name:NICHELSON, KATHY RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:RENEE
Last Name:NICHELSON
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 1:11135 S JOG RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-1807
Mailing Address - Country:US
Mailing Address - Phone:561-752-3820
Mailing Address - Fax:
Practice Address - Street 1:11135 S JOG RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-1807
Practice Address - Country:US
Practice Address - Phone:561-752-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14227225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant