Healthcare Provider Details

I. General information

NPI: 1639211089
Provider Name (Legal Business Name): KELLY MARONEY VINSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANN MARONEY PA

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 FALLING WATERS BLVD SUITE A
LINDENHURST IL
60046-6793
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-356-9300
  • Fax: 847-356-7260
Mailing address:
  • Phone: 847-570-2040
  • Fax: 847-733-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002418
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: