Provider Demographics
NPI:1487227732
Name:DONNELLY, KRYSTA C
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:C
Last Name:DONNELLY
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 1:16 ARTIST DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1306
Mailing Address - Country:US
Mailing Address - Phone:631-457-9245
Mailing Address - Fax:
Practice Address - Street 1:1 CRAIG B GARIEPY AVE
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-2820
Practice Address - Country:US
Practice Address - Phone:631-650-6545
Practice Address - Fax:631-650-6546
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist