Provider Demographics
NPI:1144664731
Name:MASTRIDGE, KRISTYN LEIGH
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:LEIGH
Last Name:MASTRIDGE
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 1:98 CIRCLE DR W
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4294
Mailing Address - Country:US
Mailing Address - Phone:631-741-2075
Mailing Address - Fax:
Practice Address - Street 1:5225 NESCONSET HWY STE 30
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-473-4284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY662082121174400000X
NY662081121174400000X
NY662080121174400000X
NY662079121174400000X
NY350688091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist