Provider Demographics
NPI:1477184943
Name:FELICIANO, KRYSTLE MARIE
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:MARIE
Last Name:FELICIANO
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:EXT MELENDEZ
Mailing Address - Street 2:CALLE F #56
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:939-278-9579
Mailing Address - Fax:
Practice Address - Street 1:LOIZA VALLEYSHOPPING CENTER
Practice Address - Street 2:LOCAL AA-6
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-256-0273
Practice Address - Fax:787-876-7856
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR24812104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty