Provider Demographics
NPI:1639635766
Name:REVUTSKY, INNA
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:REVUTSKY
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 1:24 MENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-3412
Mailing Address - Country:US
Mailing Address - Phone:191-730-6322
Mailing Address - Fax:
Practice Address - Street 1:326 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5602
Practice Address - Country:US
Practice Address - Phone:917-306-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00135600171100000X
NYF40378301363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty