Provider Demographics
NPI:1396972378
Name:LIRIANO, KERTIS
Entity type:Individual
Prefix:
First Name:KERTIS
Middle Name:
Last Name:LIRIANO
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 1:5331 195TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1734
Mailing Address - Country:US
Mailing Address - Phone:917-412-7565
Mailing Address - Fax:
Practice Address - Street 1:5331 195TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1734
Practice Address - Country:US
Practice Address - Phone:917-412-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005990-1376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLIRIANOPEREZMedicaid