Healthcare Provider Details

I. General information

NPI: 1376644096
Provider Name (Legal Business Name): TAVORIA KELLAM MW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 5TH AVE 2253 THIRD AVENUE 3RD FL
NEW YORK NY
10029-6503
US

IV. Provider business mailing address

1309 5TH AVE #29A
NEW YORK NY
10029-3123
US

V. Phone/Fax

Practice location:
  • Phone: 212-289-6650
  • Fax: 212-360-5088
Mailing address:
  • Phone: 212-876-9448
  • Fax: 212-689-3988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF000971-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: