MEDICARE: STELLA KOUTSAKIS-RALLAKIS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	664488	NY

General Provider Information

NPI Number	:	1790316974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STELLA KOUTSAKIS-RALLAKIS RN

Provider Business Mailing Address
First Line	:	370 90TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-5871
Country	:	US
Telephone Number	:	917-528-1719
Fax Number	:

Provider Business Practice Location Address
First Line	:	8502 RIDGE BLVD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-4308
Country	:	US
Telephone Number	:	718-836-8096
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2020
Last Update Date	:	01/28/2020

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