Provider Demographics
NPI:1689444671
Name:NELSON, KELLY JO (CMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:NELSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 CALIFORNIA ST NW TRLR 8
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-1530
Mailing Address - Country:US
Mailing Address - Phone:507-621-1269
Mailing Address - Fax:
Practice Address - Street 1:903 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-3117
Practice Address - Country:US
Practice Address - Phone:507-621-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCERTIFIED225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist