Provider Demographics
NPI:1083595441
Name:MCDONALD, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 LILY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WAPWALLOPEN
Mailing Address - State:PA
Mailing Address - Zip Code:18660-8842
Mailing Address - Country:US
Mailing Address - Phone:570-255-4578
Mailing Address - Fax:
Practice Address - Street 1:64 RIDGWAY DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-9263
Practice Address - Country:US
Practice Address - Phone:570-255-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI005304208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation