Provider Demographics
NPI:1407464506
Name:HERETSUN-ROUSSONICOLOS, LILIYA
Entity Type:Individual
Prefix:
First Name:LILIYA
Middle Name:
Last Name:HERETSUN-ROUSSONICOLOS
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 1:1488 SE VILLAGE GREEN DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3411
Mailing Address - Country:US
Mailing Address - Phone:772-777-4745
Mailing Address - Fax:772-777-4833
Practice Address - Street 1:1488 SE VILLAGE GREEN DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3411
Practice Address - Country:US
Practice Address - Phone:722-301-1497
Practice Address - Fax:321-676-8508
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies