Provider Demographics
NPI:1124777198
Name:DMITRIEFF, NINA (DNH, LMT, MLD-C, CCT)
Entity type:Individual
Prefix:DR
First Name:NINA
Middle Name:
Last Name:DMITRIEFF
Suffix:
Gender:F
Credentials:DNH, LMT, MLD-C, CCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 THATCHING LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7376
Mailing Address - Country:US
Mailing Address - Phone:917-710-2766
Mailing Address - Fax:
Practice Address - Street 1:1014 CANTON ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3615
Practice Address - Country:US
Practice Address - Phone:404-904-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013198225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty