Healthcare Provider Details

I. General information

NPI: 1770557696
Provider Name (Legal Business Name): JEFF BRYAN NELSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 PENROSE LN APT 542
LENEXA KS
66219-8171
US

IV. Provider business mailing address

8800 PENROSE LN APT 542
LENEXA KS
66219-8171
US

V. Phone/Fax

Practice location:
  • Phone: 913-940-1233
  • Fax:
Mailing address:
  • Phone: 913-940-1233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: