Provider Demographics
NPI:1750885844
Name:NETTLES, BLAIR ELISE (DPT, PT)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:ELISE
Last Name:NETTLES
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17909 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3980
Mailing Address - Country:US
Mailing Address - Phone:540-931-3037
Mailing Address - Fax:571-363-2753
Practice Address - Street 1:17909 N SHORE DR
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-3980
Practice Address - Country:US
Practice Address - Phone:540-931-3037
Practice Address - Fax:571-363-2753
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist