Provider Demographics
NPI:1124516828
Name:KOITHAN, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:KOITHAN
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 1:6780 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-9504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6780 SHAWNEE RD
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-9504
Practice Address - Country:US
Practice Address - Phone:716-525-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant