Basic Information
Provider Information | |||||||||
NPI: | 1750755179 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MABEE | ||||||||
FirstName: | KRYSTLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 707 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 109402650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453337575 | ||||||||
FaxNumber: | 8453337139 | ||||||||
Practice Location | |||||||||
Address1: | 475 STATE ROUTE 17M | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | NY | ||||||||
PostalCode: | 109504169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453337830 | ||||||||
FaxNumber: | 8453337475 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2015 | ||||||||
LastUpdateDate: | 08/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 340106 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 340106 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 04401727 | 05 | NY |   | MEDICAID |