Provider Demographics
NPI:1508619370
Name:KELLY, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N THOMAS RD APT 204A
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1768
Mailing Address - Country:US
Mailing Address - Phone:330-351-4225
Mailing Address - Fax:
Practice Address - Street 1:265 N THOMAS RD APT 204A
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1768
Practice Address - Country:US
Practice Address - Phone:330-351-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide