Provider Demographics
NPI:1851986244
Name:LIGHTFOOT, KATHY CAMELLIA (PHYSICIAN ASSISTANTS)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:CAMELLIA
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRC, 251 BAYVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2816
Mailing Address - Country:US
Mailing Address - Phone:443-889-5989
Mailing Address - Fax:443-740-2834
Practice Address - Street 1:BRC, 251 BAYVIEW BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2816
Practice Address - Country:US
Practice Address - Phone:443-889-5989
Practice Address - Fax:443-740-2834
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant