Provider Demographics
NPI:1063088268
Name:NELSON, KUIANNA ALEXIS (LMT, BCTMB)
Entity type:Individual
Prefix:
First Name:KUIANNA
Middle Name:ALEXIS
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PARSONAGE ST # 141
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4758
Mailing Address - Country:US
Mailing Address - Phone:857-237-7182
Mailing Address - Fax:
Practice Address - Street 1:124 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-3312
Practice Address - Country:US
Practice Address - Phone:857-237-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT02304225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist