MEDICARE: KELLY M NELSON DO

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	207Q00000X	Family Medicine Physician	O1165	ID

General Provider Information

NPI Number	:	1720293749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M NELSON DO

Provider Business Mailing Address
First Line	:	2003 KOOTENAI HEALTH WAY
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83814-6051
Country	:	US
Telephone Number	:	208-625-5085
Fax Number	:	208-625-5731

Provider Business Practice Location Address
First Line	:	566 W PRAIRIE AVE
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-7766
Country	:	US
Telephone Number	:	208-625-5155
Fax Number	:	208-625-5156

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

Provider Enumeration Date	:	05/12/2007
Last Update Date	:	04/26/2024

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