MEDICARE: MRS. LISA LYNN NELSON RPT

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	2305003392	VA

General Provider Information

NPI Number	:	1649734500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA LYNN NELSON RPT

Provider Business Mailing Address
First Line	:	705 WINTERGREEN DR
Second Line	:
City	:	PURCELLVILLE
State	:	VA
Zip	:	20132-3290
Country	:	US
Telephone Number	:	540-338-2973
Fax Number	:

Provider Business Practice Location Address
First Line	:	6066 LEESBURG PIKE STE 900
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-2240
Country	:	US
Telephone Number	:	703-820-2001
Fax Number	:

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

Provider Enumeration Date	:	01/24/2019
Last Update Date	:	01/24/2019

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