Healthcare Provider Details

I. General information

NPI: 1053968966
Provider Name (Legal Business Name): KRYSTAL RICHARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2019
Last Update Date: 08/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14833 WELLER LN
ROSEDALE NY
11422-2811
US

IV. Provider business mailing address

14833 WELLER LN
ROSEDALE NY
11422-2811
US

V. Phone/Fax

Practice location:
  • Phone: 917-349-1358
  • Fax:
Mailing address:
  • Phone: 917-349-1358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF309212-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: