MEDICARE: KELLY NELSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1114301892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY NELSON

Provider Business Mailing Address
First Line	:	847 N MARSHFIELD AVE # 1F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5132
Country	:	US
Telephone Number	:	763-607-6819
Fax Number	:

Provider Business Practice Location Address
First Line	:	847 N MARSHFIELD AVE # 1F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5132
Country	:	US
Telephone Number	:	763-607-6819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/13/2015

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Directions to “ KELLY NELSON ” Practice Location

Language	Start Address	Practice Location

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