Provider Demographics
NPI:1619447489
Name:BAEZ, KRYSTINA ASHLEY (LPN)
Entity Type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:ASHLEY
Last Name:BAEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 BRUCKNER BLVD APT 9C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-4540
Mailing Address - Country:US
Mailing Address - Phone:718-350-6264
Mailing Address - Fax:
Practice Address - Street 1:190 MERCER ST # 646
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-1502
Practice Address - Country:US
Practice Address - Phone:212-677-3400
Practice Address - Fax:646-532-2811
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333675-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-5562204Medicaid