Healthcare Provider Details

I. General information

NPI: 1225258239
Provider Name (Legal Business Name): KELLY ANN MAUGHAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 VINELAND RD 304
ORLANDO FL
32819-7800
US

IV. Provider business mailing address

2301 LAKE DEBRA DR 135
ORLANDO FL
32835-6641
US

V. Phone/Fax

Practice location:
  • Phone: 407-354-3906
  • Fax: 407-354-3907
Mailing address:
  • Phone: 407-405-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 20325
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: