Provider Demographics
NPI:1922555762
Name:NILSSEN, JOANNA (OT)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:NILSSEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2142 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4142
Mailing Address - Country:US
Mailing Address - Phone:718-819-6805
Mailing Address - Fax:347-841-9109
Practice Address - Street 1:4112 OUTLOOK BLVD STE 96
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1667
Practice Address - Country:US
Practice Address - Phone:719-562-6200
Practice Address - Fax:719-562-6225
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020889225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100146108Medicare PIN