Provider Demographics
NPI:1699762302
Name:MCNULTY, KRISTINE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 QUINCY AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1739
Mailing Address - Country:US
Mailing Address - Phone:570-961-0851
Mailing Address - Fax:570-344-4285
Practice Address - Street 1:748 QUINCY AVE
Practice Address - Street 2:STE 2A
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1739
Practice Address - Country:US
Practice Address - Phone:570-961-0851
Practice Address - Fax:570-344-4285
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070398L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001850323Medicaid
PA049070Medicare PIN
PA001850323Medicaid