Provider Demographics
NPI:1659543049
Name:CREAVEN, KIM (MS, LAC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CREAVEN
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:TINEVRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LAC
Mailing Address - Street 1:129 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2237
Mailing Address - Country:US
Mailing Address - Phone:516-998-5561
Mailing Address - Fax:
Practice Address - Street 1:129 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2237
Practice Address - Country:US
Practice Address - Phone:516-998-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002755171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist