Provider Demographics
NPI:1043465172
Name:MARONEY, KIM (PTA)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:MARONEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:MARONEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:8455 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5066
Mailing Address - Country:US
Mailing Address - Phone:352-567-5910
Mailing Address - Fax:
Practice Address - Street 1:8455 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5066
Practice Address - Country:US
Practice Address - Phone:352-382-0939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA2259225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106898OtherMEDICARE ID