Provider Demographics
NPI:1518410182
Name:CHAMBERLAIN, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:CHAMBERLAIN
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 80
Mailing Address - Street 2:
Mailing Address - City:ELLISBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13636-0080
Mailing Address - Country:US
Mailing Address - Phone:315-286-6481
Mailing Address - Fax:
Practice Address - Street 1:420 GAFFNEY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1823
Practice Address - Country:US
Practice Address - Phone:315-286-6481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator