Healthcare Provider Details

I. General information

NPI: 1295161875
Provider Name (Legal Business Name): CRYSTELLE MARIE ROVILLOS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 57TH ST
NEW YORK NY
10019-2902
US

IV. Provider business mailing address

500 W 57TH ST
NEW YORK NY
10019-2902
US

V. Phone/Fax

Practice location:
  • Phone: 212-376-1810
  • Fax:
Mailing address:
  • Phone: 212-293-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number673686-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: