Provider Demographics
NPI:1225258239
Name:MAUGHAN, KELLY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:MAUGHAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LAKE DEBRA DR
Mailing Address - Street 2:135
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6641
Mailing Address - Country:US
Mailing Address - Phone:407-405-3828
Mailing Address - Fax:
Practice Address - Street 1:5979 VINELAND RD
Practice Address - Street 2:304
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7800
Practice Address - Country:US
Practice Address - Phone:407-354-3906
Practice Address - Fax:407-354-3907
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20325225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant