Provider Demographics
NPI:1326289836
Name:SALLAVANTI, KATHRYN ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANN
Last Name:SALLAVANTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1606
Mailing Address - Country:US
Mailing Address - Phone:570-457-8364
Mailing Address - Fax:570-457-9635
Practice Address - Street 1:315 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1606
Practice Address - Country:US
Practice Address - Phone:570-457-8364
Practice Address - Fax:570-457-9635
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027430260001Medicaid
PA1027430260001Medicaid