Provider Demographics
NPI:1548798135
Name:FINE, KAITLYN MOLLIE (PA)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MOLLIE
Last Name:FINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 N HANCOCK ST APT 509
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2357
Mailing Address - Country:US
Mailing Address - Phone:412-841-1992
Mailing Address - Fax:
Practice Address - Street 1:825 OLD LANCASTER RD STE 340
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3235
Practice Address - Country:US
Practice Address - Phone:610-525-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty