Healthcare Provider Details

I. General information

NPI: 1003528050
Provider Name (Legal Business Name): KRISSA MATARLO-SMITH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 FORT WASHINGTON AVE
NEW YORK NY
10032-3739
US

IV. Provider business mailing address

37 8TH ST
RIDGEFIELD PARK NJ
07660-1005
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9940
  • Fax:
Mailing address:
  • Phone: 201-410-6108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311115
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: