Provider Demographics
NPI:1699103465
Name:SMIRNOVA, OLESYA
Entity type:Individual
Prefix:
First Name:OLESYA
Middle Name:
Last Name:SMIRNOVA
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 1:74 MCVEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6208
Mailing Address - Country:US
Mailing Address - Phone:646-492-2233
Mailing Address - Fax:
Practice Address - Street 1:74 MCVEIGH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6208
Practice Address - Country:US
Practice Address - Phone:646-492-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY770768131174400000X
NY772253131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist