=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639211089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MARONEY VINSON PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 07/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3021 FALLING WATERS BLVD SUITE A
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-6793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-356-9300
-----------------------------------------------------
Fax | 847-356-7260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3021 FALLING WATERS BLVD SUITE A
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-6793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-436-0837
-----------------------------------------------------
Fax | 847-436-0837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------