Provider Demographics
NPI:1396436150
Name:KRIVULIN, ELENA
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:KRIVULIN
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 1:8 HILSINGER RD
Mailing Address - Street 2:P.O. BOX 412
Mailing Address - City:MOUNT TABOR
Mailing Address - State:NJ
Mailing Address - Zip Code:07878
Mailing Address - Country:US
Mailing Address - Phone:201-919-2097
Mailing Address - Fax:
Practice Address - Street 1:99 HAWLEY LN STE 1102
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1204
Practice Address - Country:US
Practice Address - Phone:203-666-8145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349313-01363LF0000X
NJ26NJ00892800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily