Provider Demographics
NPI:1366077869
Name:FUZAYLOV, POLINA
Entity type:Individual
Prefix:
First Name:POLINA
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20381 NE 30TH AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1521
Mailing Address - Country:US
Mailing Address - Phone:646-326-8981
Mailing Address - Fax:
Practice Address - Street 1:20381 NE 30TH AVE APT 208
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1521
Practice Address - Country:US
Practice Address - Phone:646-326-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17386224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant