Provider Demographics
NPI:1164501995
Name:KIPNIS, ILENA (PT)
Entity Type:Individual
Prefix:
First Name:ILENA
Middle Name:
Last Name:KIPNIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-1721
Mailing Address - Country:US
Mailing Address - Phone:201-941-8667
Mailing Address - Fax:201-941-2578
Practice Address - Street 1:590 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1721
Practice Address - Country:US
Practice Address - Phone:201-941-8667
Practice Address - Fax:201-941-2578
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00411700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ661650QCBMedicare PIN
NJ661650S30Medicare PIN