Provider Demographics
NPI:1275035420
Name:CUNNINGHAM, KRYSTEN JEAN
Entity Type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:JEAN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:SUMMITVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12781-0293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 MOUNT VERNON RD APT 2
Practice Address - Street 2:
Practice Address - City:WURTSBORO
Practice Address - State:NY
Practice Address - Zip Code:12790-5335
Practice Address - Country:US
Practice Address - Phone:845-551-8007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309935164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse