Healthcare Provider Details

I. General information

NPI: 1184232639
Provider Name (Legal Business Name): KRISTYN R DEMARTINIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD
REGO PARK NY
11374-4357
US

IV. Provider business mailing address

4830 40TH ST APT 6B
SUNNYSIDE NY
11104-4133
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0246
  • Fax:
Mailing address:
  • Phone: 631-681-8837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number089455
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: