Provider Demographics
NPI:1023692290
Name:MIMS, NELIA FORTSON (DPT)
Entity type:Individual
Prefix:
First Name:NELIA
Middle Name:FORTSON
Last Name:MIMS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NELIA
Other - Middle Name:
Other - Last Name:FORTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2227 US HIGHWAY 41 N
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2227 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2749
Practice Address - Country:US
Practice Address - Phone:229-353-6188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist