Provider Demographics
NPI:1003152620
Name:MCKITTRICK, LAURIE LYN
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:LYN
Last Name:MCKITTRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127-1707
Mailing Address - Country:US
Mailing Address - Phone:856-904-2908
Mailing Address - Fax:
Practice Address - Street 1:102 DAVIS ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-1707
Practice Address - Country:US
Practice Address - Phone:856-904-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA07636646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist