Provider Demographics
NPI:1992315485
Name:KATAYEVA, LIAANORA
Entity type:Individual
Prefix:
First Name:LIAANORA
Middle Name:
Last Name:KATAYEVA
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 1:495 WASHINGTON AVE APT 5C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2328
Mailing Address - Country:US
Mailing Address - Phone:347-217-5618
Mailing Address - Fax:
Practice Address - Street 1:2464 CONEY ISLAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5009
Practice Address - Country:US
Practice Address - Phone:888-389-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist