Healthcare Provider Details

I. General information

NPI: 1336615541
Provider Name (Legal Business Name): KRISTA ANN MOSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2539 MIDDLE COUNTRY RD
CENTEREACH NY
11720-3551
US

IV. Provider business mailing address

384 W 18TH ST
DEER PARK NY
11729-6340
US

V. Phone/Fax

Practice location:
  • Phone: 631-737-6434
  • Fax: 631-738-1226
Mailing address:
  • Phone: 631-456-1646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: