Provider Demographics
NPI:1073963914
Name:MANION, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MANION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 NEWBERN CIR
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-3348
Mailing Address - Country:US
Mailing Address - Phone:863-965-1288
Mailing Address - Fax:863-967-1297
Practice Address - Street 1:125 NEWBERN CIR
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3348
Practice Address - Country:US
Practice Address - Phone:863-965-1288
Practice Address - Fax:863-967-1297
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant