Provider Demographics
NPI:1548813280
Name:NIELSEN, KELLIE (DPT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3436 SACKETT LN
Mailing Address - Street 2:
Mailing Address - City:WINTERS
Mailing Address - State:CA
Mailing Address - Zip Code:95694-9687
Mailing Address - Country:US
Mailing Address - Phone:206-518-1012
Mailing Address - Fax:
Practice Address - Street 1:803 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3426
Practice Address - Country:US
Practice Address - Phone:530-391-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2967632251N0400X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA296763OtherPHYSICAL THERAPY BOARD OF CALIFORNIA