Basic Information
| Provider Information | |||||||||
| NPI: | 1811323611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELK | ||||||||
| FirstName: | BRADIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562781357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 5TH AVE N | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562964500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205638269 | ||||||||
| FaxNumber: | 3205638175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9494 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.