Basic Information
| Provider Information | |||||||||
| NPI: | 1841873312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALONEY | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | RAYE | ||||||||
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| Credential: | CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 LEXI LN | ||||||||
| Address2: | |||||||||
| City: | BROOKLAND | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724178009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703513219 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 E JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724058413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2021 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 190702 | AR | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.