Provider Demographics
NPI:1790223428
Name:CIANCA, KRISTAL
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:CIANCA
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 1:6007 56TH RD
Mailing Address - Street 2:APT 2RR
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-2320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6007 56TH RD
Practice Address - Street 2:APT 2RR
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2320
Practice Address - Country:US
Practice Address - Phone:347-682-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0057781171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist