Provider Demographics
NPI:1598163545
Name:KITAEV, BOULAT
Entity Type:Individual
Prefix:
First Name:BOULAT
Middle Name:
Last Name:KITAEV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 E 22ND ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4830
Mailing Address - Country:US
Mailing Address - Phone:917-302-6670
Mailing Address - Fax:347-702-9687
Practice Address - Street 1:2333 E 22ND ST APT 2F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4830
Practice Address - Country:US
Practice Address - Phone:917-302-6670
Practice Address - Fax:347-702-9687
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY623253163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse