Healthcare Provider Details

I. General information

NPI: 1205343134
Provider Name (Legal Business Name): KATEY MARIE NELSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2017
Last Update Date: 12/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 CENTENNIAL CIR
ANCHORAGE AK
99504-1480
US

IV. Provider business mailing address

25117 SW PARKWAY AVE STE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 907-333-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number60760251
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number126334
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: