Healthcare Provider Details

I. General information

NPI: 1548262504
Provider Name (Legal Business Name): KELLEY SHULTZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT ST
CONCORD NH
03301-7539
US

IV. Provider business mailing address

250 PLEASANT ST
CONCORD NH
03301-7539
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-7200
  • Fax: 603-228-7307
Mailing address:
  • Phone: 603-228-7200
  • Fax: 603-228-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.055406
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9556
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: