Basic Information
| Provider Information | |||||||||
| NPI: | 1548350382 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIVILETTI | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195632896 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 FREEDOM PKWY STE C | ||||||||
| Address2: | |||||||||
| City: | PITTSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273124939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195450911 | ||||||||
| FaxNumber: | 9195450096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS012949 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2014-02119 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NCP490B | 01 | NC | MEDICARE PTAN | OTHER |