Provider Demographics
NPI:1215531090
Name:KICHIKOV, KISHTYA
Entity type:Individual
Prefix:
First Name:KISHTYA
Middle Name:
Last Name:KICHIKOV
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 1:2553 E 7TH ST APT 1D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6241
Mailing Address - Country:US
Mailing Address - Phone:917-702-2698
Mailing Address - Fax:
Practice Address - Street 1:2553 E 7TH ST APT 1D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6241
Practice Address - Country:US
Practice Address - Phone:917-702-2698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
NYCERTIFIED174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist