Healthcare Provider Details

I. General information

NPI: 1295102242
Provider Name (Legal Business Name): LYAYSAN ZAGIDULLINA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 ARLO RD APT 2A
STATEN ISLAND NY
10301-4704
US

IV. Provider business mailing address

55 ARLO RD APT 2A
STATEN ISLAND NY
10301-4704
US

V. Phone/Fax

Practice location:
  • Phone: 347-603-5552
  • Fax:
Mailing address:
  • Phone: 347-603-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number705129-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: