Provider Demographics
NPI:1770850828
Name:DAVALLI, KRISTIE R (CRNP)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:R
Last Name:DAVALLI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6535 N. CHARLES ST.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-1544
Mailing Address - Country:US
Mailing Address - Phone:443-849-4270
Mailing Address - Fax:443-849-4280
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR168131363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care