Provider Demographics
NPI:1932646841
Name:NELSON, KAYTLIN (PTA)
Entity Type:Individual
Prefix:
First Name:KAYTLIN
Middle Name:
Last Name:NELSON
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 1:1037 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3415
Mailing Address - Country:US
Mailing Address - Phone:208-743-1795
Mailing Address - Fax:208-743-1791
Practice Address - Street 1:1037 21ST ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3415
Practice Address - Country:US
Practice Address - Phone:208-743-1795
Practice Address - Fax:208-743-1791
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA4953225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant