Provider Demographics
NPI:1447674114
Name:MALICKY, KEVIN (CRNP F-NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MALICKY
Suffix:
Gender:M
Credentials:CRNP F-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 FREDERICK RD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-7475
Mailing Address - Country:US
Mailing Address - Phone:814-937-4147
Mailing Address - Fax:
Practice Address - Street 1:1225 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2350
Practice Address - Country:US
Practice Address - Phone:818-643-8485
Practice Address - Fax:814-643-8755
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF0214324363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102948711Medicaid
PA349540G0FOtherMEDICARE