Provider Demographics
NPI:1194970251
Name:NELSON, TEGAN LEIGH (PT)
Entity type:Individual
Prefix:
First Name:TEGAN
Middle Name:LEIGH
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 1:2531 CLEVELAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-4900
Mailing Address - Country:US
Mailing Address - Phone:239-334-7000
Mailing Address - Fax:239-334-7070
Practice Address - Street 1:2531 CLEVELAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-4900
Practice Address - Country:US
Practice Address - Phone:239-334-7000
Practice Address - Fax:239-334-7070
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10492225100000X
FLPT35708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2126OtherSTATE OF MINNESOTA ATHLETIC TRAINER REGISTRATION