Provider Demographics
NPI:1275183774
Name:MALONEY, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MALONEY
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 1:8030 SOQUEL AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2096
Mailing Address - Country:US
Mailing Address - Phone:408-366-1735
Mailing Address - Fax:
Practice Address - Street 1:2 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-9561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297917225100000X
NY044876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist