Provider Demographics
NPI:1457942526
Name:KLINPUN-RUDNICK, WANNHA
Entity Type:Individual
Prefix:
First Name:WANNHA
Middle Name:
Last Name:KLINPUN-RUDNICK
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 1:920 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 48TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2918
Practice Address - Country:US
Practice Address - Phone:718-283-8486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2022-04-18
Deactivation Date:2021-10-29
Deactivation Code:
Reactivation Date:2022-04-18
Provider Licenses
StateLicense IDTaxonomies
NYP114115221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty