Provider Demographics
NPI:1538402888
Name:TYLER, KELLIE R (LMT)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:R
Last Name:TYLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4470
Mailing Address - Country:US
Mailing Address - Phone:845-331-0300
Mailing Address - Fax:845-331-1130
Practice Address - Street 1:324 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4470
Practice Address - Country:US
Practice Address - Phone:845-331-0300
Practice Address - Fax:845-331-1130
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013345174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist