Provider Demographics
NPI:1992278683
Name:GVASALIA, NANA
Entity type:Individual
Prefix:
First Name:NANA
Middle Name:
Last Name:GVASALIA
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 1:2525 W 2ND ST APT 3D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-6269
Mailing Address - Country:US
Mailing Address - Phone:917-673-7307
Mailing Address - Fax:
Practice Address - Street 1:2525 W 2ND ST APT 3D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-6269
Practice Address - Country:US
Practice Address - Phone:917-673-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY576446163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse