Healthcare Provider Details

I. General information

NPI: 1992240147
Provider Name (Legal Business Name): MRS. YETUNDE D KUPOLUYI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2016
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11423 198TH ST
SAINT ALBANS NY
11412-2820
US

IV. Provider business mailing address

11423 198TH ST
SAINT ALBANS NY
11412-2820
US

V. Phone/Fax

Practice location:
  • Phone: 646-400-8034
  • Fax:
Mailing address:
  • Phone: 646-400-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: