Provider Demographics
NPI:1124023197
Name:NANCE, ALLEN TYLER (PT)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:TYLER
Last Name:NANCE
Suffix:
Gender:
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:PO BOX 200880
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-0880
Mailing Address - Country:US
Mailing Address - Phone:678-837-7176
Mailing Address - Fax:404-777-1311
Practice Address - Street 1:6510 HIGHWAY 90 STE D
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5015
Practice Address - Country:US
Practice Address - Phone:228-875-7259
Practice Address - Fax:228-438-2038
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000047302251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3652689Medicaid