Healthcare Provider Details

I. General information

NPI: 1750885844
Provider Name (Legal Business Name): BLAIR ELISE NETTLES DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17909 N SHORE DR
PURCELLVILLE VA
20132-3980
US

IV. Provider business mailing address

17909 N SHORE DR
PURCELLVILLE VA
20132-3980
US

V. Phone/Fax

Practice location:
  • Phone: 540-931-3037
  • Fax: 571-363-2753
Mailing address:
  • Phone: 540-931-3037
  • Fax: 571-363-2753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305211755
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: