MEDICARE: MRS. TAMMY RENA KELLEY LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA23357	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C2023	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1982817649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAMMY RENA KELLEY LMT

Provider Business Mailing Address
First Line	:	4320 W EL PRADO BLVD
Second Line	:	SUITE 25
City	:	TAMPA
State	:	FL
Zip	:	33629-8498
Country	:	US
Telephone Number	:	813-839-1808
Fax Number	:

Provider Business Practice Location Address
First Line	:	4320 W EL PRADO BLVD
Second Line	:	SUITE 25
City	:	TAMPA
State	:	FL
Zip	:	33629-8498
Country	:	US
Telephone Number	:	813-839-1808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	05/14/2014

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