Healthcare Provider Details

I. General information

NPI: 1770670697
Provider Name (Legal Business Name): KRYSTEN L AVERY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1979 MARCUS AVE STE 206
NORTH NEW HYDE PARK NY
11042-1002
US

IV. Provider business mailing address

8256 NADELL ST
DELTON MI
49046-8202
US

V. Phone/Fax

Practice location:
  • Phone: 877-506-0002
  • Fax:
Mailing address:
  • Phone: 269-267-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPOP10
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004395
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: