Provider Demographics
NPI:1053893545
Name:NELSON, KARYSSA JEANNE (OTR)
Entity type:Individual
Prefix:
First Name:KARYSSA
Middle Name:JEANNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KARYSSA
Other - Middle Name:JEANNE
Other - Last Name:KIMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11389 S STATE ROAD 63
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-7195
Mailing Address - Country:US
Mailing Address - Phone:307-660-7801
Mailing Address - Fax:
Practice Address - Street 1:1320 WALNUT ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3931
Practice Address - Country:US
Practice Address - Phone:307-660-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.0122608225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist