Provider Demographics
NPI:1821081241
Name:NELSON, KELLY K (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5625 JONAMAC PL
Mailing Address - Street 2:APT. 3A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6126
Mailing Address - Country:US
Mailing Address - Phone:540-977-2714
Mailing Address - Fax:
Practice Address - Street 1:21 HIGHLAND AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2201
Practice Address - Country:US
Practice Address - Phone:540-344-9213
Practice Address - Fax:540-345-7559
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA01012386482080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
126F1OtherBLUE CROSS
NC89126F1Medicaid
126F1OtherBLUE CROSS
2280137AMedicare ID - Type Unspecified