Healthcare Provider Details

I. General information

NPI: 1275183774
Provider Name (Legal Business Name): KELLY ANN MALONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COULTER RD
CLIFTON SPRINGS NY
14432-1122
US

IV. Provider business mailing address

8030 SOQUEL AVE STE 200
SANTA CRUZ CA
95062-2096
US

V. Phone/Fax

Practice location:
  • Phone: 315-462-9561
  • Fax:
Mailing address:
  • Phone: 408-366-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number297917
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number044876
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: