Provider Demographics
NPI:1962818864
Name:KELLY, TYLER P (NP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13345 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3318
Mailing Address - Country:US
Mailing Address - Phone:317-396-1300
Mailing Address - Fax:
Practice Address - Street 1:120 AVON MARKET PL STE 100
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6021
Practice Address - Country:US
Practice Address - Phone:317-396-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005109A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71005109BOtherCSR PRESCRIPTIVE AUTHORITY
IN201252820Medicaid
IN71005109AOtherAPN PRESCRIPTIVE AUTHORITY
IN28189341AOtherRN LICENSE
IN201252820Medicaid