Provider Demographics
NPI:1285323675
Name:CHRISTIE, KENNETH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CHRISTIE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RAILY CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1676
Mailing Address - Country:US
Mailing Address - Phone:347-366-0960
Mailing Address - Fax:
Practice Address - Street 1:78 TODT HILL RD STE 205
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4528
Practice Address - Country:US
Practice Address - Phone:718-691-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349282-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily