Provider Demographics
NPI:1699715219
Name:WEBER, NANCY JO (PT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:JO
Last Name:WEBER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:JO
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1407 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2602
Mailing Address - Country:US
Mailing Address - Phone:605-624-7246
Mailing Address - Fax:605-624-7177
Practice Address - Street 1:1407 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2602
Practice Address - Country:US
Practice Address - Phone:605-624-7246
Practice Address - Fax:605-624-7177
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9260355OtherDAKOTACARE
SD4992211OtherSOUTH DAKOTA BLUE CROSS BLUE SHIELD
SD19685OtherAVERA
SDS102507Medicare PIN