Provider Demographics
NPI:1588137020
Name:NELSEN, ALYSSA LYNN (DPT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNN
Last Name:NELSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:LYNN
Other - Last Name:DITTMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 E LUCAS ST
Mailing Address - Street 2:
Mailing Address - City:KNOB NOSTER
Mailing Address - State:MO
Mailing Address - Zip Code:65336-1134
Mailing Address - Country:US
Mailing Address - Phone:660-563-9800
Mailing Address - Fax:660-563-9801
Practice Address - Street 1:106 E LUCAS ST
Practice Address - Street 2:
Practice Address - City:KNOB NOSTER
Practice Address - State:MO
Practice Address - Zip Code:65336-1134
Practice Address - Country:US
Practice Address - Phone:660-563-9800
Practice Address - Fax:660-563-9801
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07055225100000X
MO2022030328225100000X, 208100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500047913Medicaid