Provider Demographics
NPI:1679352207
Name:KELLEY, TYLA NICOLE
Entity type:Individual
Prefix:
First Name:TYLA
Middle Name:NICOLE
Last Name:KELLEY
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 1:3 LOVING KINDNESS WAY
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909
Mailing Address - Country:US
Mailing Address - Phone:843-819-2310
Mailing Address - Fax:
Practice Address - Street 1:3 LOVING KINDNESS WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909
Practice Address - Country:US
Practice Address - Phone:843-819-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant