Provider Demographics
NPI:1073264750
Name:DETETTA, KRISTA M (RN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:M
Last Name:DETETTA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-3845
Mailing Address - Country:US
Mailing Address - Phone:856-558-0630
Mailing Address - Fax:
Practice Address - Street 1:11 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-3845
Practice Address - Country:US
Practice Address - Phone:856-558-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR17438200163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency