Provider Demographics
NPI:1669032116
Name:KUGBLENU, PRISCELA LIZETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:PRISCELA
Middle Name:LIZETTE
Last Name:KUGBLENU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N PINE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1737
Mailing Address - Country:US
Mailing Address - Phone:518-512-6321
Mailing Address - Fax:
Practice Address - Street 1:407 ALBANY SHAKER RD
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12211-1900
Practice Address - Country:US
Practice Address - Phone:518-435-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant