Provider Demographics
NPI:1952656522
Name:MATCHETT EVANS, KRISTY MARIE
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:MARIE
Last Name:MATCHETT EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KRISTY
Other - Middle Name:MARIE
Other - Last Name:MATCHETT-EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2649 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3218
Mailing Address - Country:US
Mailing Address - Phone:631-650-4816
Mailing Address - Fax:
Practice Address - Street 1:2649 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3218
Practice Address - Country:US
Practice Address - Phone:631-650-4816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608198051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist