MEDICARE: MS. TERRA RENEE NELSON MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	29298	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29298	OTHER	CA	CALIFORNIA PT LICENSE

General Provider Information

NPI Number	:	1205113875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERRA RENEE NELSON MPT

Provider Business Mailing Address
First Line	:	4141 34TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-2109
Country	:	US
Telephone Number	:	619-955-3459
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 34TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-2109
Country	:	US
Telephone Number	:	619-955-3459
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	11/10/2011

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