Provider Demographics
NPI:1306330600
Name:MIDDEN, NYSSA ROSINA
Entity type:Individual
Prefix:
First Name:NYSSA
Middle Name:ROSINA
Last Name:MIDDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3493 SPRINGER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14855 OLYMPIC DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9522
Practice Address - Country:US
Practice Address - Phone:707-995-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-13014225100000X
OR62358225100000X
NM5066225100000X
VA2305211199225100000X
WA60847038225100000X
CA293808225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist