Healthcare Provider Details

I. General information

NPI: 1760745178
Provider Name (Legal Business Name): KRISTINA CHARLESWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8984 NEW ALBION ROAD
LITTLE VALLEY NY
14755
US

IV. Provider business mailing address

8984 NEW ALBION ROAD
LITTLE VALLEY NY
14755
US

V. Phone/Fax

Practice location:
  • Phone: 716-938-6007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: