Provider Demographics
NPI:1750947586
Name:MALONEY, KAITLYN (MS ED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MALONEY
Suffix:
Gender:F
Credentials:MS ED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 JAN LN APT 2
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:IL
Mailing Address - Zip Code:62924-0045
Mailing Address - Country:US
Mailing Address - Phone:302-353-6468
Mailing Address - Fax:
Practice Address - Street 1:125 JAN LN APT 2
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:IL
Practice Address - Zip Code:62924-0045
Practice Address - Country:US
Practice Address - Phone:302-353-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20000177992081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty