Provider Demographics
NPI:1164458691
Name:KRYVICKY, LORRAINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:
Last Name:KRYVICKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 SE 6TH AVENUE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-5252
Mailing Address - Country:US
Mailing Address - Phone:561-440-8020
Mailing Address - Fax:
Practice Address - Street 1:550 SE 6TH AVENUE SUITE 100
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483
Practice Address - Country:US
Practice Address - Phone:561-440-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9101864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P74840Medicare UPIN
E8741ZMedicare ID - Type Unspecified