Provider Demographics
NPI:1497222079
Name:VILLACRES, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:VILLACRES
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 1:506 GRANDVIEW AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1996
Mailing Address - Country:US
Mailing Address - Phone:347-350-0596
Mailing Address - Fax:
Practice Address - Street 1:506 GRANDVIEW AVE APT 2R
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1996
Practice Address - Country:US
Practice Address - Phone:347-350-0596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY630171662OtherMETRO PLUS