Healthcare Provider Details

I. General information

NPI: 1831810118
Provider Name (Legal Business Name): KELLIANNE KINANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CENTRAL MAINE XING
GARDINER ME
04345-6320
US

IV. Provider business mailing address

5 CENTRAL MAINE XING
GARDINER ME
04345-6320
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-6608
  • Fax: 207-582-2258
Mailing address:
  • Phone: 207-582-6608
  • Fax: 207-582-2258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2539
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: