Provider Demographics
NPI:1699335067
Name:TAT, SHELLY (DO)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:TAT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:KY
Mailing Address - Zip Code:41076-1530
Mailing Address - Country:US
Mailing Address - Phone:859-781-4111
Mailing Address - Fax:859-441-5214
Practice Address - Street 1:2626 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-1530
Practice Address - Country:US
Practice Address - Phone:859-781-4111
Practice Address - Fax:859-441-5214
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05196204D00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program