Provider Demographics
NPI:1205366929
Name:FRUSTACI, LEIDY KATERINE
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:KATERINE
Last Name:FRUSTACI
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 1:14 GAMBIER AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-3834
Mailing Address - Country:US
Mailing Address - Phone:978-618-4315
Mailing Address - Fax:
Practice Address - Street 1:14 GAMBIER AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-3834
Practice Address - Country:US
Practice Address - Phone:978-618-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program