Healthcare Provider Details

I. General information

NPI: 1659296002
Provider Name (Legal Business Name): CAMILLA NELSON PT, DPT
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: MILLIE NELSON

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

2180 S 2200 E
SALT LAKE CITY UT
84109-1133
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1000
  • Fax:
Mailing address:
  • Phone: 801-898-9564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number14292114-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: