Provider Demographics
NPI:1053401208
Name:NELMS, STACY NICOLE (PT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:NELMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:NICOLE
Other - Last Name:BUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2415 MCCALLIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-624-2696
Mailing Address - Fax:423-697-2025
Practice Address - Street 1:2415 MCCALLIE AVENUE
Practice Address - Street 2:
Practice Address - City:CHATTANOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-624-2696
Practice Address - Fax:423-697-2025
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000003749225100000X
GAPT007435225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3067481OtherBLUE CROSS BLUE SHIELD
TNTN0100OtherJOHN DEERE
TN3647242Medicare PIN