Provider Demographics
NPI:1245696798
Name:DEROSA, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:DEROSA
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 1:177 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4464
Mailing Address - Country:US
Mailing Address - Phone:860-866-7115
Mailing Address - Fax:
Practice Address - Street 1:590 MIDDLEBURY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2562
Practice Address - Country:US
Practice Address - Phone:860-866-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT128313163W00000X
CT006291163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No163W00000XNursing Service ProvidersRegistered Nurse