Provider Demographics
NPI:1386372662
Name:RIVERA, KRYSTAL KAYLEEN
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:KAYLEEN
Last Name:RIVERA
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 1:8403 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4833
Mailing Address - Country:US
Mailing Address - Phone:718-899-9060
Mailing Address - Fax:
Practice Address - Street 1:8403 57TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4833
Practice Address - Country:US
Practice Address - Phone:718-899-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist