Provider Demographics
NPI:1265982623
Name:KRIVAK, EMMA
Entity type:Individual
Prefix:MISS
First Name:EMMA
Middle Name:
Last Name:KRIVAK
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 1:349 MEADOWLARK LANE
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350
Mailing Address - Country:US
Mailing Address - Phone:219-262-4616
Mailing Address - Fax:
Practice Address - Street 1:349 MEADOW LARK LN
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-1951
Practice Address - Country:US
Practice Address - Phone:219-262-4616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program