Individual
TASHIANA KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2611 UNIVERSITY BLVD N APT C203, JACKSONVILLE, FL 32211-3287
(904) 248-2208
Mailing address
2611 UNIVERSITY BLVD N APT C203, JACKSONVILLE, FL 32211-3287
(904) 248-2208
Taxonomy
Speciality
Code
Description
License number
State
305S00000X
Point of Service
Primary
W689477
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
K400801859330
STATE IDENTIFICATION
FL
Enumeration date
10/15/2020
Last updated
10/15/2020
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