Provider Demographics
NPI:1639211089
Name:VINSON, KELLY MARONEY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARONEY
Last Name:VINSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MARONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3021 FALLING WATERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6793
Mailing Address - Country:US
Mailing Address - Phone:847-436-0837
Mailing Address - Fax:847-436-0837
Practice Address - Street 1:3021 FALLING WATERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-6793
Practice Address - Country:US
Practice Address - Phone:847-356-9300
Practice Address - Fax:847-356-7260
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ38956Medicare UPIN