Provider Demographics
NPI:1760745178
Name:CHARLESWORTH, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:CHARLESWORTH
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 1:8984 NEW ALBION ROAD
Mailing Address - Street 2:
Mailing Address - City:LITTLE VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8984 NEW ALBION ROAD
Practice Address - Street 2:
Practice Address - City:LITTLE VALLEY
Practice Address - State:NY
Practice Address - Zip Code:14755
Practice Address - Country:US
Practice Address - Phone:716-938-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist