Provider Demographics
NPI:1639628670
Name:GARAVAGLIA, KRISTINA NICCOLE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:NICCOLE
Last Name:GARAVAGLIA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:NICCOLE
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2914 N BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-1208
Mailing Address - Country:US
Mailing Address - Phone:813-228-7696
Mailing Address - Fax:813-228-0677
Practice Address - Street 1:26677 W 12 MILE RD STE 166
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1514
Practice Address - Country:US
Practice Address - Phone:313-306-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9321512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily