=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134343940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESIREE D. NELSON-KELLY, DPM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 TENNYSON ST
-----------------------------------------------------
City | CARTERET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07008-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-541-1118
-----------------------------------------------------
Fax | 732-541-2111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 TENNYSON ST
-----------------------------------------------------
City | CARTERET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07008-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-541-1118
-----------------------------------------------------
Fax | 732-541-2111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST
-----------------------------------------------------
Name | DESIREE DIANE NELSON-KELLY
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 732-541-1118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 25MD002581
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------