1720174980 NPI number — DR. SHELLY BRODJESKI NELSON MD

Table of content: DR. SHELLY BRODJESKI NELSON MD (NPI 1720174980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720174980 NPI number — DR. SHELLY BRODJESKI NELSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
SHELLY
Provider Middle Name:
BRODJESKI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRODJESKI
Provider Other First Name:
SHELLY
Provider Other Middle Name:
JOAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720174980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1435 45TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53144-1175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-552-9115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 S LAYTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-385-6600
Provider Business Practice Location Address Fax Number:
414-385-6612
Provider Enumeration Date:
10/05/2006

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: 207QA0505X , with the licence number:  31522 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2005672 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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