Provider Demographics
NPI:1740789718
Name:KAMYNINA, YESENIYA (NP)
Entity Type:Individual
Prefix:
First Name:YESENIYA
Middle Name:
Last Name:KAMYNINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 NEW DORP LN STE A
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2364
Mailing Address - Country:US
Mailing Address - Phone:718-876-6220
Mailing Address - Fax:718-876-5969
Practice Address - Street 1:12046 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1204
Practice Address - Country:US
Practice Address - Phone:718-793-3341
Practice Address - Fax:718-268-1666
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308549363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05418997Medicaid