Healthcare Provider Details

I. General information

NPI: 1508324575
Provider Name (Legal Business Name): KRYSTEN WONDRACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 CEDAR HILL AVE
WYCKOFF NJ
07481-2150
US

IV. Provider business mailing address

541 CEDAR HILL AVE
WYCKOFF NJ
07481-2150
US

V. Phone/Fax

Practice location:
  • Phone: 551-815-1000
  • Fax: 551-815-1001
Mailing address:
  • Phone: 551-815-1000
  • Fax: 551-815-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25NJ00881700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: