Provider Demographics
NPI:1679135925
Name:POLENTARUTTI, KRISTEN (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:POLENTARUTTI
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1130 MCBRIDE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3806
Mailing Address - Country:US
Mailing Address - Phone:973-785-2277
Mailing Address - Fax:973-785-2355
Practice Address - Street 1:195 US HIGHWAY 46 STE 100
Practice Address - Street 2:
Practice Address - City:MINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:07803-3163
Practice Address - Country:US
Practice Address - Phone:973-366-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-07
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00530100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical