Healthcare Provider Details

I. General information

NPI: 1063940385
Provider Name (Legal Business Name): LIZA YEFIMOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

578 TRAVIS AVE
STATEN ISLAND NY
10314-4802
US

IV. Provider business mailing address

578 TRAVIS AVE
STATEN ISLAND NY
10314-4802
US

V. Phone/Fax

Practice location:
  • Phone: 646-578-0612
  • Fax:
Mailing address:
  • Phone: 646-578-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: