Provider Demographics
NPI:1023170792
Name:MALANEY, KELLIE MICHELE (PAC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MICHELE
Last Name:MALANEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 WILLISTON RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6491
Mailing Address - Country:US
Mailing Address - Phone:802-861-0200
Mailing Address - Fax:802-861-0210
Practice Address - Street 1:1775 WILLISTON RD STE 220
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6491
Practice Address - Country:US
Practice Address - Phone:802-861-0200
Practice Address - Fax:802-861-0210
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9001155Medicaid