Healthcare Provider Details

I. General information

NPI: 1982394912
Provider Name (Legal Business Name): KELLY TYUKODY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 BLACK SWAN DR STE 202
LEWES DE
19958-4991
US

IV. Provider business mailing address

1050 INDUSTRIAL DR STE 210
MIDDLETOWN DE
19709-2803
US

V. Phone/Fax

Practice location:
  • Phone: 302-449-6476
  • Fax: 302-449-2047
Mailing address:
  • Phone: 302-724-6344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0014696
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: