Provider Demographics
NPI:1750328282
Name:NELSON-KELLY, DESIREE DIANE (DPM)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:DIANE
Last Name:NELSON-KELLY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 RESEARCH PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4664
Mailing Address - Country:US
Mailing Address - Phone:732-643-2070
Mailing Address - Fax:732-643-2015
Practice Address - Street 1:3000 ESSEX RD
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-2631
Practice Address - Country:US
Practice Address - Phone:732-643-2070
Practice Address - Fax:732-643-2015
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002581213EP1101X
NYN005661-1213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
27-07975OtherEVERCARE
NJ8393907Medicaid
522114204DOtherBCBS OF NJ
NJ8393907Medicaid
038071XNMMedicare PIN
522114204DOtherBCBS OF NJ