Provider Demographics
NPI:1497592299
Name:CALLAN, KRYSTLE
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:CALLAN
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 1:195 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4218
Mailing Address - Country:US
Mailing Address - Phone:516-737-2093
Mailing Address - Fax:
Practice Address - Street 1:111 BEACH DR
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4929
Practice Address - Country:US
Practice Address - Phone:631-417-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311860-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty