Provider Demographics
NPI:1982092110
Name:KELLEY, TIFFANY DEE (PTA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 NE COUNTY ROAD 354
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-5410
Mailing Address - Country:US
Mailing Address - Phone:386-965-8737
Mailing Address - Fax:
Practice Address - Street 1:555 N BYRON BUTLER PKWY
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2315
Practice Address - Country:US
Practice Address - Phone:850-223-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21521225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant