Provider Demographics
NPI:1124407465
Name:SUPONITSKY, IANINA (AGNP)
Entity Type:Individual
Prefix:
First Name:IANINA
Middle Name:
Last Name:SUPONITSKY
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290421
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-0421
Mailing Address - Country:US
Mailing Address - Phone:347-713-3023
Mailing Address - Fax:718-208-4022
Practice Address - Street 1:1773 E 12TH ST
Practice Address - Street 2:#4D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1051
Practice Address - Country:US
Practice Address - Phone:347-713-3023
Practice Address - Fax:718-208-4022
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307084-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health