Provider Demographics
NPI:1134343940
Name:DESIREE D. NELSON-KELLY, DPM
Entity type:Organization
Organization Name:DESIREE D. NELSON-KELLY, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:NELSON-KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-541-1118
Mailing Address - Street 1:32 TENNYSON ST
Mailing Address - Street 2:
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-2330
Mailing Address - Country:US
Mailing Address - Phone:732-541-1118
Mailing Address - Fax:732-541-2111
Practice Address - Street 1:32 TENNYSON ST
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008-2330
Practice Address - Country:US
Practice Address - Phone:732-541-1118
Practice Address - Fax:732-541-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD002581213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60009551OtherHORIZON NJ HEALTH
NJ2116024OtherUNITED HEALTHCARE
NJP3239784OtherOXFORD
NJ2K9378OtherHEALTHNET
NJ=========001OtherQUALCARE
NJ60009551OtherHORIZON NJ HEALTH
NJ=========0OtherHORIZON BLUE CROSS BLUE S
NJP3239784OtherOXFORD