Provider Demographics
NPI:1942696414
Name:NELSON, DARYL
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 STEEPLECREST CIR
Mailing Address - Street 2:APT 302
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-9084
Mailing Address - Country:US
Mailing Address - Phone:602-818-1613
Mailing Address - Fax:
Practice Address - Street 1:2800 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40209-1818
Practice Address - Country:US
Practice Address - Phone:602-818-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-12
Last Update Date:2015-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer