Provider Demographics
NPI:1386119881
Name:PAVLOVA, POLINA (FNP-BC)
Entity type:Individual
Prefix:
First Name:POLINA
Middle Name:
Last Name:PAVLOVA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 CAMINITO EL RINCON UNIT 221
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3501
Mailing Address - Country:US
Mailing Address - Phone:619-632-7915
Mailing Address - Fax:
Practice Address - Street 1:1730 ALPINE BLVD STE 205
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3878
Practice Address - Country:US
Practice Address - Phone:619-326-4445
Practice Address - Fax:619-722-1721
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA822420OtherCALIFORNIA BOARD OF REGISTERED NURSING
CA95009998OtherCALIFORNIA BOARD OF REGISTERED NURSING NP LICENSE