Healthcare Provider Details

I. General information

NPI: 1205366929
Provider Name (Legal Business Name): LEIDY KATERINE FRUSTACI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 GAMBIER AVE
WORCESTER MA
01604-3834
US

IV. Provider business mailing address

14 GAMBIER AVE
WORCESTER MA
01604-3834
US

V. Phone/Fax

Practice location:
  • Phone: 978-618-4315
  • Fax:
Mailing address:
  • Phone: 978-618-4315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: