1134630528 NPI number — TABITHA KELLY PA

Table of content: TABITHA KELLY PA (NPI 1134630528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134630528 NPI number — TABITHA KELLY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
TABITHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROACH
Provider Other First Name:
TABITHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134630528
Entity Type Code:
Individual
Replacement NPI:
1134630528
Last Update Date:
01/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 INDUSTRIAL BLVD STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79602-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-480-2900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 INDUSTRIAL BLVD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABILENE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79602-8004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-480-2900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)