Provider Demographics
NPI:1346629730
Name:KELLY, TAMMY JEAN (WA60557072)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JEAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:WA60557072
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 NW 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7382
Mailing Address - Country:US
Mailing Address - Phone:360-567-8752
Mailing Address - Fax:
Practice Address - Street 1:1300 COLUMBIA ST APT 206
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2939
Practice Address - Country:US
Practice Address - Phone:360-567-8752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist