Provider Demographics
NPI:1316821481
Name:KELLEY, TIA (MA)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:KELLEY-STOLLMACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:9009 TALL SKY TRCE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-7217
Mailing Address - Country:US
Mailing Address - Phone:804-517-3680
Mailing Address - Fax:
Practice Address - Street 1:9009 TALL SKY TRCE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724-7217
Practice Address - Country:US
Practice Address - Phone:804-517-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-02
Last Update Date:2025-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program