Provider Demographics
NPI:1700506565
Name:KELLUM, TRICIA (NP)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:KELLUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COMMERCE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2878
Mailing Address - Country:US
Mailing Address - Phone:302-726-1081
Mailing Address - Fax:
Practice Address - Street 1:100 COMMERCE DR STE 300
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2878
Practice Address - Country:US
Practice Address - Phone:302-726-1081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA287482163W00000X, 363LP0808X
SC29862363LP0808X
DEL8-0010769363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse