Healthcare Provider Details

I. General information

NPI: 1114662731
Provider Name (Legal Business Name): KELSEY SUZANNE MANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 E FLAMINGO RD STE 220A
LAS VEGAS NV
89119-0850
US

IV. Provider business mailing address

5853 ENCHANTED PALMS AVE
LAS VEGAS NV
89139-5612
US

V. Phone/Fax

Practice location:
  • Phone: 309-883-9748
  • Fax:
Mailing address:
  • Phone: 309-883-9748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: