Provider Demographics
NPI:1588253611
Name:IVANOVA, OLENA (CRNP-FAMILY)
Entity type:Individual
Prefix:
First Name:OLENA
Middle Name:
Last Name:IVANOVA
Suffix:
Gender:F
Credentials:CRNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-0525
Mailing Address - Country:US
Mailing Address - Phone:443-629-5584
Mailing Address - Fax:
Practice Address - Street 1:16220 FREDERICK RD STE 200
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-4086
Practice Address - Country:US
Practice Address - Phone:301-519-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR206867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily