Provider Demographics
NPI:1710986997
Name:KELLY, TAMMY ROSE (MD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:ROSE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MILL ST # MSM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-3900
Practice Address - Street 1:4465 CORDATA PKWY STE 102
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8037
Practice Address - Country:US
Practice Address - Phone:360-752-5280
Practice Address - Fax:360-752-5282
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9040207V00000X
WAMD61508204207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0020-18783Medicaid
NV36835Medicare ID - Type Unspecified
H37013Medicare UPIN