Provider Demographics
NPI:1720174980
Name:NELSON, SHELLY BRODJESKI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:BRODJESKI
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHELLY
Other - Middle Name:JOAN
Other - Last Name:BRODJESKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1435 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1175
Mailing Address - Country:US
Mailing Address - Phone:262-552-9115
Mailing Address - Fax:
Practice Address - Street 1:1555 S LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-385-6600
Practice Address - Fax:414-385-6612
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31522207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2005672Medicaid
F48778Medicare UPIN