Healthcare Provider Details

I. General information

NPI: 1285528844
Provider Name (Legal Business Name): SYDNIE NICOLE NOWLEN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 GALAXIE DR
JACKSON MS
39206-4335
US

IV. Provider business mailing address

PO BOX 75
MADISON MS
39130-0075
US

V. Phone/Fax

Practice location:
  • Phone: 769-216-3288
  • Fax: 601-510-9012
Mailing address:
  • Phone: 769-216-3288
  • Fax: 601-510-9012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA7601
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: