Provider Demographics
NPI:1154826212
Name:TANLER, KELSEY RAE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:RAE
Last Name:TANLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20415 TILBERG ST
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7402
Mailing Address - Country:US
Mailing Address - Phone:703-400-0962
Mailing Address - Fax:
Practice Address - Street 1:20415 TILBERG ST
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7402
Practice Address - Country:US
Practice Address - Phone:703-400-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer