Basic Information
Provider Information | |||||||||
NPI: | 1619422656 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | KAITLYN | ||||||||
MiddleName: | CORA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TRUMP | ||||||||
OtherFirstName: | KAITLYN | ||||||||
OtherMiddleName: | CORA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2895 HAMILTON BLVD STE 105 | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181046172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108413555 | ||||||||
FaxNumber: | 6108413558 | ||||||||
Practice Location | |||||||||
Address1: | 2895 HAMILTON BLVD STE 105 | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181046172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108413555 | ||||||||
FaxNumber: | 6108413558 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2016 | ||||||||
LastUpdateDate: | 07/26/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT025287 | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.