Healthcare Provider Details

I. General information

NPI: 1972330082
Provider Name (Legal Business Name): ELEANORA SULTANOVA DOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELEANORA SULTANOVA ELEANORA SULTANOVA

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 ORMSBY AVE
STATEN ISLAND NY
10309-4018
US

IV. Provider business mailing address

96 ORMSBY AVE
STATEN ISLAND NY
10309-4018
US

V. Phone/Fax

Practice location:
  • Phone: 347-500-1954
  • Fax:
Mailing address:
  • Phone: 347-500-1954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1845255241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: