Provider Demographics
NPI:1639635766
Name:REVUTSKY, INNA
Entity type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:REVUTSKY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-3412
Mailing Address - Country:US
Mailing Address - Phone:212-271-7200
Mailing Address - Fax:
Practice Address - Street 1:356 W 18TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4401
Practice Address - Country:US
Practice Address - Phone:212-271-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00135600171100000X
NYF40378301363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty