Basic Information
| Provider Information | |||||||||
| NPI: | 1003152620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKITTRICK | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 102 DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191271707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569042908 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 102 DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191271707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569042908 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2012 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 07636646 | PA | Y | Other Service Providers | Specialist |
No ID Information.