Healthcare Provider Details

I. General information

NPI: 1275588634
Provider Name (Legal Business Name): KELLY M MALENA PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY M VAVRO PA C

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE C300
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

ONE INDEPENDENCE POINTE SUITE 212
GREENVILLE SC
29615-4566
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-8272
  • Fax: 864-454-2875
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1085
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1085
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: