Provider Demographics
NPI:1376689547
Name:KELLY, TARA (ARNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16264 SENECA CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-2112
Mailing Address - Country:US
Mailing Address - Phone:954-252-9330
Mailing Address - Fax:
Practice Address - Street 1:3220 S DOUGLAS RD STE B
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2734
Practice Address - Country:US
Practice Address - Phone:954-436-8444
Practice Address - Fax:954-436-1159
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2170262363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics