Provider Demographics
NPI:1861457806
Name:MALONEY, KATHLEEN THAYER (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:THAYER
Last Name:MALONEY
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 1:44 CHARITY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1039
Mailing Address - Country:US
Mailing Address - Phone:802-343-9403
Mailing Address - Fax:
Practice Address - Street 1:FAHC
Practice Address - Street 2:111 COLCHESTER AVE
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1063
Practice Address - Country:US
Practice Address - Phone:802-847-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030766363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000233Medicaid