Provider Demographics
NPI:1275588634
Name:MALENA, KELLY M (PA C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MALENA
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:VAVRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:ONE INDEPENDENCE POINTE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE C300
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-8272
Practice Address - Fax:864-454-2875
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1085363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1085Medicaid
AA1246Medicare UPIN
SC1085Medicaid
SCAA12465373Medicare PIN