Provider Demographics
NPI:1033700372
Name:NELSON, TASSIE EUBANK (PT)
Entity type:Individual
Prefix:MRS
First Name:TASSIE
Middle Name:EUBANK
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 NW SECLUDED GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8502
Mailing Address - Country:US
Mailing Address - Phone:386-623-5306
Mailing Address - Fax:
Practice Address - Street 1:246 NW SECLUDED GLN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8502
Practice Address - Country:US
Practice Address - Phone:386-623-5306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist