Provider Demographics
NPI:1487323416
Name:MELLINGER, COURTNEY NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:MELLINGER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 SPLIT OAK DR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-8902
Mailing Address - Country:US
Mailing Address - Phone:316-251-2283
Mailing Address - Fax:
Practice Address - Street 1:600 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-8780
Practice Address - Country:US
Practice Address - Phone:316-283-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant