1659396737 NPI number — DR. KELLY KEEFE NELSON MD

Table of content: DR. KELLY KEEFE NELSON MD (NPI 1659396737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659396737 NPI number — DR. KELLY KEEFE NELSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
KELLY
Provider Middle Name:
KEEFE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659396737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 PEQUOT PARK RD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
WESTBROOK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06498-2856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-399-6167
Provider Business Mailing Address Fax Number:
860-399-6730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 PEQUOT PARK RD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
WESTBROOK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06498-2856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-399-6167
Provider Business Practice Location Address Fax Number:
860-399-6730
Provider Enumeration Date:
07/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  30067 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30067 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 24371 . This is a "STATE DCP" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".