Provider Demographics
NPI:1316316474
Name:PRESTA, KRIEZEL CHARMEL ERSANDO (PA-C)
Entity type:Individual
Prefix:
First Name:KRIEZEL CHARMEL
Middle Name:ERSANDO
Last Name:PRESTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRIEZEL CHARMEL
Other - Middle Name:LU
Other - Last Name:ERSANDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:52 WASHINGTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1724
Mailing Address - Country:US
Mailing Address - Phone:203-672-2800
Mailing Address - Fax:203-672-2801
Practice Address - Street 1:52 WASHINGTON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1724
Practice Address - Country:US
Practice Address - Phone:203-672-2800
Practice Address - Fax:203-672-2801
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant