Provider Demographics
NPI:1225458607
Name:KHANYUTIN, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:KHANYUTIN
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 1:530 NEW BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3654
Mailing Address - Country:US
Mailing Address - Phone:732-324-5138
Mailing Address - Fax:732-324-5139
Practice Address - Street 1:183 S ORANGE AVE
Practice Address - Street 2:BHSB, E-1452
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2757
Practice Address - Country:US
Practice Address - Phone:973-972-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA101260002084P0800X
NY2930272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program