Provider Demographics
NPI:1801146683
Name:SUYUNOVA, KRISTINA CASEY
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:CASEY
Last Name:SUYUNOVA
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 1:9915 66TH AVE
Mailing Address - Street 2:APT.5D
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3660
Mailing Address - Country:US
Mailing Address - Phone:917-330-5772
Mailing Address - Fax:
Practice Address - Street 1:9915 66TH AVE
Practice Address - Street 2:APT.5D
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3660
Practice Address - Country:US
Practice Address - Phone:917-330-5772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist