Provider Demographics
NPI:1154797926
Name:SHIMUNOVA, LIANA
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:SHIMUNOVA
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 1:9839 65TH RD APT 1E
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3517
Mailing Address - Country:US
Mailing Address - Phone:646-945-8629
Mailing Address - Fax:
Practice Address - Street 1:9839 65RD #1E
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374
Practice Address - Country:US
Practice Address - Phone:646-945-8629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY820197141174400000X
NY820196141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist