Provider Demographics
NPI:1508208133
Name:KIVITZ, COLLEEN M (CRNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:KIVITZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 E HAVERFORD RD
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3819
Mailing Address - Country:US
Mailing Address - Phone:610-649-6400
Mailing Address - Fax:610-649-7971
Practice Address - Street 1:933 E HAVERFORD RD
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3819
Practice Address - Country:US
Practice Address - Phone:610-649-6400
Practice Address - Fax:610-649-7971
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013045363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMLHC TIN
PA31498HK1Medicare PIN