Provider Demographics
NPI:1801338934
Name:CRISCUOLA, KIM MARIE
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:CRISCUOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:CRISCUOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11 TRILLIUM PL
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-7117
Mailing Address - Country:US
Mailing Address - Phone:516-314-7206
Mailing Address - Fax:
Practice Address - Street 1:11 TRILLIUM PL
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-7117
Practice Address - Country:US
Practice Address - Phone:516-314-7206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY828305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist