Basic Information
Provider Information | |||||||||
NPI: | 1750328282 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON-KELLY | ||||||||
FirstName: | DESIREE | ||||||||
MiddleName: | DIANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5525 RESEARCH PARK DRIVE | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212284664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7326432070 | ||||||||
FaxNumber: | 7326432015 | ||||||||
Practice Location | |||||||||
Address1: | 3000 ESSEX RD | ||||||||
Address2: |   | ||||||||
City: | TINTON FALLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 077532631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7326432070 | ||||||||
FaxNumber: | 7326432015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 05/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | MD002581 | NJ | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213EP1101X | N005661-1 | NY | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 27-07975 | 01 |   | EVERCARE | OTHER | 8393907 | 05 | NJ |   | MEDICAID | 522114204D | 01 |   | BCBS OF NJ | OTHER |