Basic Information
| Provider Information | |||||||||
| NPI: | 1164159059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | TAMMIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 LACKAWANNA AVE LOT 12 | ||||||||
| Address2: | |||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178153201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702042809 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 S RAISINVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342437340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2022 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 4704392600 | MI | Y | Nursing Service Providers | Registered Nurse | Community Health | 163WP0808X | RN616419 | PA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.