Provider Demographics
NPI:1184243057
Name:MCCLINE, LIANI KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:LIANI
Middle Name:KELLY
Last Name:MCCLINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748860
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374
Mailing Address - Country:US
Mailing Address - Phone:623-535-0740
Mailing Address - Fax:
Practice Address - Street 1:10815 W MCDOWELL RD STE 301
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5016
Practice Address - Country:US
Practice Address - Phone:623-535-0740
Practice Address - Fax:623-512-4460
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTP8091207V00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty