Provider Demographics
NPI:1629732466
Name:KELLY, TAWNYA MISHELLE (HAS)
Entity Type:Individual
Prefix:
First Name:TAWNYA
Middle Name:MISHELLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:TAWNYA
Other - Middle Name:M
Other - Last Name:WINTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4498
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1593
Practice Address - Street 1:320 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2922
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-524-1813
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA61174893237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1780658419OtherWALLA WALLA CLINIC NPI