Provider Demographics
NPI:1215267349
Name:KELLY, TAMMY BOYETTE (PA-C)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:BOYETTE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:RAYE
Other - Last Name:BOYETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7051 ALVARADO RD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-8901
Mailing Address - Country:US
Mailing Address - Phone:619-460-7775
Mailing Address - Fax:
Practice Address - Street 1:7051 ALVARADO RD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-8901
Practice Address - Country:US
Practice Address - Phone:619-460-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003655363AM0700X
FLPA9107316363AM0700X
NC0010-02138363AM0700X
CAPA54682363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1215267349OtherTRICARE/HEALTHNET
FLY0J7GOtherBCBS OF FL
FL009498400Medicaid
FL009498400Medicaid