Healthcare Provider Details

I. General information

NPI: 1134630528
Provider Name (Legal Business Name): TABITHA KELLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TABITHA ROACH

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23900 MILTON ELLENDALE HWY
MILTON DE
19968-2714
US

IV. Provider business mailing address

1515 SAVANNAH RD FL 2
LEWES DE
19958-1675
US

V. Phone/Fax

Practice location:
  • Phone: 302-684-5635
  • Fax: 866-546-6159
Mailing address:
  • Phone: 302-645-3499
  • Fax: 302-644-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0012230
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: