Provider Demographics
NPI:1093588485
Name:KIYANG, JUSTINE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:KIYANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 PORTSIDE CT
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-2393
Mailing Address - Country:US
Mailing Address - Phone:302-333-1648
Mailing Address - Fax:
Practice Address - Street 1:193 PORTSIDE CT
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-2393
Practice Address - Country:US
Practice Address - Phone:302-333-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL8-0010585363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health