Provider Demographics
NPI:1063641058
Name:TANTILLO, KRISTIN NOELLE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:NOELLE
Last Name:TANTILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 BRANDI DR
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-5802
Mailing Address - Country:US
Mailing Address - Phone:716-930-1060
Mailing Address - Fax:716-298-4779
Practice Address - Street 1:3117 MILITARY RD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-4813
Practice Address - Country:US
Practice Address - Phone:716-930-1060
Practice Address - Fax:716-298-4778
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019795174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist