Provider Demographics
NPI:1952907917
Name:MACULLOCH, KAITLYN ANNE (CRNP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ANNE
Last Name:MACULLOCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:ANNE
Other - Last Name:SWARTZLANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1000 E MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-808-4772
Practice Address - Fax:570-808-6174
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023619363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health