Provider Demographics
NPI:1619560638
Name:YAKUTILOVA, SOFYA B
Entity Type:Individual
Prefix:
First Name:SOFYA
Middle Name:B
Last Name:YAKUTILOVA
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 1:8511 LEFFERTS BLVD APT 3F
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3036
Mailing Address - Country:US
Mailing Address - Phone:347-607-7528
Mailing Address - Fax:
Practice Address - Street 1:8511 LEFFERTS BLVD APT 3F
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3036
Practice Address - Country:US
Practice Address - Phone:347-607-7528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator