Healthcare Provider Details

I. General information

NPI: 1114116589
Provider Name (Legal Business Name): KRISTEN MALONE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JOSEPH SIEWICK DR
FAIRFAX VA
22033-1709
US

IV. Provider business mailing address

12 GILL ST STE 3000
WOBURN MA
01801-1728
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-3094
  • Fax:
Mailing address:
  • Phone: 781-937-4522
  • Fax: 781-937-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002623
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: