Provider Demographics
NPI:1609116722
Name:SAMARA-KELLOGG, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:SAMARA-KELLOGG
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 1:7892 MOUNT RANIER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-2998
Mailing Address - Country:US
Mailing Address - Phone:904-240-1223
Mailing Address - Fax:
Practice Address - Street 1:7892 MOUNT RANIER DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-2998
Practice Address - Country:US
Practice Address - Phone:904-240-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11615225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist