Provider Demographics
NPI:1487914834
Name:FACCIOLO, KRISTEN LEIGH
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:FACCIOLO
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 1:78 OMEGA DR
Mailing Address - Street 2:BLDG C
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2064
Mailing Address - Country:US
Mailing Address - Phone:302-368-2883
Mailing Address - Fax:302-368-2892
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-0001
Practice Address - Country:US
Practice Address - Phone:302-733-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0012183207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease