Provider Demographics
NPI:1265279012
Name:MIKALIC, KAITLYN MARIE (MMS, MPH, PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:MIKALIC
Suffix:
Gender:F
Credentials:MMS, MPH, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 BROOKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:FURLONG
Mailing Address - State:PA
Mailing Address - Zip Code:18925-1274
Mailing Address - Country:US
Mailing Address - Phone:215-622-1088
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA065722363A00000X
PAOA006909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant