Provider Demographics
NPI:1932862497
Name:KUBLANOVSKY, ALISA
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:KUBLANOVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:KUBLANOVSKAYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:7316 SANTA MONICA BLVD APT 112
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6671
Mailing Address - Country:US
Mailing Address - Phone:424-302-2814
Mailing Address - Fax:
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily