Provider Demographics
NPI:1366080145
Name:TIEZZI, KRISTINE COLETTE
Entity type:Individual
Prefix:MISS
First Name:KRISTINE
Middle Name:COLETTE
Last Name:TIEZZI
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 1:5350 207TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1716
Mailing Address - Country:US
Mailing Address - Phone:718-225-0630
Mailing Address - Fax:
Practice Address - Street 1:5350 207TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-1716
Practice Address - Country:US
Practice Address - Phone:718-225-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program