Provider Demographics
NPI:1679109540
Name:KRYVICKY, MARA ANNE (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARA
Middle Name:ANNE
Last Name:KRYVICKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 CLUBHOUSE ESTATES CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1898
Mailing Address - Country:US
Mailing Address - Phone:561-798-4984
Mailing Address - Fax:
Practice Address - Street 1:907 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-3224
Practice Address - Country:US
Practice Address - Phone:248-762-8467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty