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General NPI Number Information
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NPI Number | 1407464506
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Entity Type | Individual
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Provider Name | LILIYA HERETSUN-ROUSSONICOLOS
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Gender | Female
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Dates
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Enumeration Date | 07/15/2020
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Last Update Date | 10/09/2020
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Provider Practice Location Address
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Address Line | 1488 SE VILLAGE GREEN DR
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-3411
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Country | US
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Telephone | 722-301-1497
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Fax | 321-676-8508
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Provider Business Mailing Address
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Address Line | 1488 SE VILLAGE GREEN DR
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-3411
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Country | US
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Telephone | 772-777-4745
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Fax | 772-777-4833
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | FL
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