Provider Demographics
NPI:1730236985
Name:NISSEN, KERRY ANNE (OT)
Entity type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:ANNE
Last Name:NISSEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2049 ROCKY STREAM RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-6611
Mailing Address - Country:US
Mailing Address - Phone:615-456-5391
Mailing Address - Fax:888-770-7861
Practice Address - Street 1:2049 ROCKY STREAM RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-6611
Practice Address - Country:US
Practice Address - Phone:615-456-5391
Practice Address - Fax:888-770-7861
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist