Provider Demographics
NPI:1932140720
Name:NELSON, ELLY (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELLY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 S BLANCHE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:IL
Mailing Address - Zip Code:62964-1107
Mailing Address - Country:US
Mailing Address - Phone:618-745-9419
Mailing Address - Fax:618-745-9421
Practice Address - Street 1:429 S BLANCHE ST
Practice Address - Street 2:
Practice Address - City:MOUNDS
Practice Address - State:IL
Practice Address - Zip Code:62964-1107
Practice Address - Country:US
Practice Address - Phone:618-745-9419
Practice Address - Fax:618-745-9421
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist