Basic Information
| Provider Information | |||||||||
| NPI: | 1295008654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNTSEN | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNY | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2791 RICHMOND AVE. | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188166440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1050 CLOVE ROAD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103013627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188166440 | ||||||||
| FaxNumber: | 7188163642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 337143 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.