Provider Demographics
NPI:1871780155
Name:NICKELSON, KELLY L (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 GAYLORD DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-2517
Mailing Address - Country:US
Mailing Address - Phone:573-642-8541
Mailing Address - Fax:573-642-8500
Practice Address - Street 1:401 GAYLORD DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-2517
Practice Address - Country:US
Practice Address - Phone:573-642-8541
Practice Address - Fax:573-642-8500
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002015010174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025432Medicare PIN