Provider Demographics
NPI:1528163516
Name:KIRK, KATHLEEN JEAN (CRNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JEAN
Last Name:KIRK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:JEAN
Other - Last Name:MACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:4115 KOTTLER DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1505
Mailing Address - Country:US
Mailing Address - Phone:215-233-9264
Mailing Address - Fax:
Practice Address - Street 1:3461 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4302
Practice Address - Country:US
Practice Address - Phone:215-823-4528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP001424H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology