Provider Demographics
NPI:1801872494
Name:LANDON-MALONE, KATHRYN (PNP-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:LANDON-MALONE
Suffix:
Gender:F
Credentials:PNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BRICKHILL AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1999
Mailing Address - Country:US
Mailing Address - Phone:207-761-4700
Mailing Address - Fax:207-761-4744
Practice Address - Street 1:100 BRICKHILL AVE
Practice Address - Street 2:SUTIE 304
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:207-761-4700
Practice Address - Fax:207-761-4744
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER038746363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENP1845Medicare ID - Type Unspecified
MES82753Medicare UPIN