Provider Demographics
NPI:1881032886
Name:SPOLYSSOV, ANDREI (RN)
Entity Type:Individual
Prefix:
First Name:ANDREI
Middle Name:
Last Name:SPOLYSSOV
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 100TH ST
Mailing Address - Street 2:2-L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8239
Mailing Address - Country:US
Mailing Address - Phone:212-844-9560
Mailing Address - Fax:
Practice Address - Street 1:317 100TH ST
Practice Address - Street 2:2-L
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-8239
Practice Address - Country:US
Practice Address - Phone:212-844-9560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY666868163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse