Provider Demographics
NPI:1174787014
Name:NELSON, KELLY SUZANNE (PT, PCS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUZANNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16910 FRANCES ST. STE. 102
Mailing Address - Street 2:CREIGHTON PEDIATRIC THERAPY
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:402-932-3355
Mailing Address - Fax:402-932-3370
Practice Address - Street 1:16910 FRANCES ST
Practice Address - Street 2:STE. 102
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2399
Practice Address - Country:US
Practice Address - Phone:402-932-3355
Practice Address - Fax:402-932-3370
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47693OtherBLUE CROSS BLUE SHIELD