Provider Demographics
NPI:1356995443
Name:KAPUSTINA, ALLA
Entity type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:KAPUSTINA
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 1:144 BAISLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11518-1824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider