Provider Demographics
NPI:1932473147
Name:KELLY, TANYA D
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:D
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 1:3801 CANAL ST STE 211
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6084
Mailing Address - Country:US
Mailing Address - Phone:504-483-1821
Mailing Address - Fax:504-483-1822
Practice Address - Street 1:3801 CANAL ST STE 211
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6084
Practice Address - Country:US
Practice Address - Phone:504-483-1821
Practice Address - Fax:504-483-1822
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker