Provider Demographics
NPI:1053882779
Name:NELSON, EMMA LEIGH
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:LEIGH
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16647 TOWNHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:IL
Mailing Address - Zip Code:60541-9219
Mailing Address - Country:US
Mailing Address - Phone:815-666-4492
Mailing Address - Fax:
Practice Address - Street 1:16647 TOWNHOUSE RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:IL
Practice Address - Zip Code:60541-9219
Practice Address - Country:US
Practice Address - Phone:815-666-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer