Individual
TAMMY BOYETTE KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
7051 ALVARADO RD, LA MESA, CA 91942-8901
(619) 460-7775
Mailing address
7051 ALVARADO RD, LA MESA, CA 91942-8901
(619) 460-7775
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
0010-02138
NC
363AM0700X
Medical Physician Assistant
0110003655
VA
363AM0700X
Medical Physician Assistant
Primary
PA54682
CA
363AM0700X
Medical Physician Assistant
PA9107316
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009498400
—
FL
01
—
1215267349
TRICARE/HEALTHNET
—
01
—
Y0J7G
BCBS OF FL
FL
Enumeration date
01/13/2010
Last updated
10/26/2018
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