Basic Information
| Provider Information | |||||||||
| NPI: | 1356825673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1216 GRAND CANYON DR | ||||||||
| Address2: | |||||||||
| City: | WENTZVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633853465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363578515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1127 TIMBER RUN DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631464482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144348361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2018 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 108641 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.