Healthcare Provider Details

I. General information

NPI: 1700338407
Provider Name (Legal Business Name): KRYSTAL COUTCHER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 CENTERVILLE RD
WARWICK RI
02886-4486
US

IV. Provider business mailing address

489 COMSTOCK PKWY
CRANSTON RI
02921-2345
US

V. Phone/Fax

Practice location:
  • Phone: 800-659-5411
  • Fax:
Mailing address:
  • Phone: 203-800-5567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01257
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number23.003718
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: