Provider Demographics
NPI:1588872238
Name:NESSLAGE, SUE ELLEN (PTA)
Entity type:Individual
Prefix:MR
First Name:SUE
Middle Name:ELLEN
Last Name:NESSLAGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3957 HIGHWAY T
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-8177
Mailing Address - Country:US
Mailing Address - Phone:573-437-5877
Mailing Address - Fax:
Practice Address - Street 1:875 DUNSFORD DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1238
Practice Address - Country:US
Practice Address - Phone:573-468-3128
Practice Address - Fax:573-860-4646
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116273225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant