Provider Demographics
NPI:1063073179
Name:FATAKHOVA, INESSA
Entity type:Individual
Prefix:MRS
First Name:INESSA
Middle Name:
Last Name:FATAKHOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 99TH ST APT 514
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2677
Mailing Address - Country:US
Mailing Address - Phone:646-464-2647
Mailing Address - Fax:
Practice Address - Street 1:49 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-2580
Practice Address - Country:US
Practice Address - Phone:718-473-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0287101235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist