Provider Demographics
NPI:1528666146
Name:KELLY, TASHIANA
Entity type:Individual
Prefix:
First Name:TASHIANA
Middle Name:
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 1:2611 UNIVERSITY BLVD N APT C203
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-3287
Mailing Address - Country:US
Mailing Address - Phone:904-248-2208
Mailing Address - Fax:
Practice Address - Street 1:2611 UNIVERSITY BLVD N APT C203
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-3287
Practice Address - Country:US
Practice Address - Phone:904-248-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW689477305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK400801859330OtherSTATE IDENTIFICATION