Provider Demographics
NPI:1912552290
Name:MIGNONE, KELLY LAMAR
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAMAR
Last Name:MIGNONE
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 1:702 LOCUST DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-4247
Mailing Address - Country:US
Mailing Address - Phone:615-509-5565
Mailing Address - Fax:
Practice Address - Street 1:373 S WILLOW ST STE 266
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5751
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:877-345-4009
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician