Provider Demographics
NPI:1649686726
Name:LASTRA-REIS, ETHEL (MS)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:LASTRA-REIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ETHEL
Other - Middle Name:
Other - Last Name:LASTRA REIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7825 4TH AVE APT B8
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3718
Mailing Address - Country:US
Mailing Address - Phone:917-836-3183
Mailing Address - Fax:
Practice Address - Street 1:7825 4TH AVE APT B8
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3718
Practice Address - Country:US
Practice Address - Phone:917-836-3183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY958000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist