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General NPI Number Information
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NPI Number | 1407206683
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Entity Type | Organization
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Legal Business Name | KELLY NELSON LLC
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Dates
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Enumeration Date | 06/17/2016
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Last Update Date | 06/17/2016
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Provider Practice Location Address
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Address Line | 10606 SYCAMORE GRN
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City | LOUISVILLE
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State | KY
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Zip | 40223-2945
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Country | US
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Telephone | 502-724-4960
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Fax |
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Provider Business Mailing Address
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Address Line | 10606 SYCAMORE GRN
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City | LOUISVILLE
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State | KY
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Zip | 40223-2945
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Country | US
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Telephone | 502-724-4960
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Fax |
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Authorized Official
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Title or Position | DEVELOPMENTAL INTERVENTIONIST
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Name | MRS. KELLY D NELSON
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Credential |
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Telephone | 502-724-4960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 199901318
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License Number State | KY
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