1174787014 NPI number — KELLY SUZANNE NELSON PT, PCS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174787014 NPI number — KELLY SUZANNE NELSON PT, PCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
KELLY
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, PCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174787014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16910 FRANCES ST. STE. 102
Provider Second Line Business Mailing Address:
CREIGHTON PEDIATRIC THERAPY
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-932-3355
Provider Business Mailing Address Fax Number:
402-932-3370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16910 FRANCES ST
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68130-2399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-932-3355
Provider Business Practice Location Address Fax Number:
402-932-3370
Provider Enumeration Date:
07/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2101 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47693 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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