Provider Demographics
NPI:1366855199
Name:KHANUKAYEVA, LALA (MS)
Entity Type:Individual
Prefix:
First Name:LALA
Middle Name:
Last Name:KHANUKAYEVA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 OCEAN AVE
Mailing Address - Street 2:APT 4 A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3151
Mailing Address - Country:US
Mailing Address - Phone:347-547-4457
Mailing Address - Fax:347-252-0222
Practice Address - Street 1:1733 SHEEPSHEAD BAY RD
Practice Address - Street 2:SUITE 36
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3728
Practice Address - Country:US
Practice Address - Phone:347-414-9990
Practice Address - Fax:347-252-0222
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205678390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program