Provider Demographics
NPI:1376644096
Name:KELLAM, TAVORIA (MW)
Entity Type:Individual
Prefix:MS
First Name:TAVORIA
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:MW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 5TH AVE
Mailing Address - Street 2:#29A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3123
Mailing Address - Country:US
Mailing Address - Phone:212-876-9448
Mailing Address - Fax:212-689-3988
Practice Address - Street 1:1176 5TH AVE
Practice Address - Street 2:2253 THIRD AVENUE 3RD FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6503
Practice Address - Country:US
Practice Address - Phone:212-289-6650
Practice Address - Fax:212-360-5088
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000971-1176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02692359Medicaid