Provider Demographics
NPI:1669147443
Name:TKACZ, KRISTA (NP-C)
Entity type:Individual
Prefix:MISS
First Name:KRISTA
Middle Name:
Last Name:TKACZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 TAILOR LN
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5699
Mailing Address - Country:US
Mailing Address - Phone:609-289-7089
Mailing Address - Fax:
Practice Address - Street 1:932 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-3646
Practice Address - Country:US
Practice Address - Phone:800-486-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01190000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner