Provider Demographics
NPI:1619338688
Name:MCILVAINE, KELLEY MULFINGER (PA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MULFINGER
Last Name:MCILVAINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:S
Other - Last Name:MULFINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4919 MEMORIAL HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7516
Mailing Address - Country:US
Mailing Address - Phone:813-333-1512
Mailing Address - Fax:813-333-1561
Practice Address - Street 1:4197 WOODLANDS PKWY
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3493
Practice Address - Country:US
Practice Address - Phone:727-786-3810
Practice Address - Fax:727-786-3855
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2023-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111274363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024945100Medicaid