Provider Demographics
NPI:1285334979
Name:PETRUSHENKA, NATALLIA
Entity type:Individual
Prefix:
First Name:NATALLIA
Middle Name:
Last Name:PETRUSHENKA
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 1:1200 HILLSIDE AVE APT 501
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-3559
Mailing Address - Country:US
Mailing Address - Phone:929-428-1102
Mailing Address - Fax:
Practice Address - Street 1:444 STOCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1295
Practice Address - Country:US
Practice Address - Phone:413-528-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1860022122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program