Basic Information
| Provider Information | |||||||||
| NPI: | 1841769593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALENOVITCH | ||||||||
| FirstName: | KRISTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8201 HENRY AVE # APYU01 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191282983 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 S BRYN MAWR AVE | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843373000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2018 | ||||||||
| LastUpdateDate: | 11/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | YM012564 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
ID Information
| ID | Type | State | Issuer | Description | 26858628 | 01 | PA | DRIVER'S LICENSE | OTHER |