Provider Demographics
NPI:1518379882
Name:KUZNICKI, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KUZNICKI
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 1:3425 37TH ST
Mailing Address - Street 2:APT 1L
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 BI-COUNTY BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735
Practice Address - Country:US
Practice Address - Phone:718-264-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1213410174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist