Provider Demographics
NPI:1760199483
Name:KELLY, TAMMY LYNN
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:KELLY
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 1:405 WISE ACRES DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-9636
Mailing Address - Country:US
Mailing Address - Phone:304-996-4025
Mailing Address - Fax:
Practice Address - Street 1:405 WISE ACRES DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-9636
Practice Address - Country:US
Practice Address - Phone:304-996-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant