Provider Demographics
NPI:1962251983
Name:OLIMJONOVA, MUKUMAOY
Entity type:Individual
Prefix:
First Name:MUKUMAOY
Middle Name:
Last Name:OLIMJONOVA
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 1:956 ROCKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-7706
Mailing Address - Country:US
Mailing Address - Phone:917-756-5222
Mailing Address - Fax:
Practice Address - Street 1:956 ROCKLAND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-7706
Practice Address - Country:US
Practice Address - Phone:917-756-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency