Provider Demographics
NPI:1962201566
Name:NELSON, RUSTIE MARIE
Entity type:Individual
Prefix:
First Name:RUSTIE
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CANDLETREE DR APT 8
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8036
Mailing Address - Country:US
Mailing Address - Phone:309-333-4678
Mailing Address - Fax:
Practice Address - Street 1:2800 MONTALUMA DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6900
Practice Address - Country:US
Practice Address - Phone:309-333-4678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.020805225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist