Provider Demographics
NPI:1063699536
Name:KUZNETSOVA, YELENA (RPH)
Entity type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:KUZNETSOVA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRIGHTON 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5304
Mailing Address - Country:US
Mailing Address - Phone:718-676-4006
Mailing Address - Fax:718-676-4027
Practice Address - Street 1:10 BRIGHTON 11TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5304
Practice Address - Country:US
Practice Address - Phone:718-676-4006
Practice Address - Fax:718-676-4027
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY49367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01764983Medicaid