Provider Demographics
NPI:1063071231
Name:ANDERSON, KELSEY NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:NICOLE
Other - Last Name:NIETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:17134 BEL RAY PL
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-5331
Practice Address - Country:US
Practice Address - Phone:816-318-0434
Practice Address - Fax:816-318-0437
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019019891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist