MEDICARE: NINO GVELESIANI MS, ANP-BC, GNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	F305936	NY
2	363LG0600X	Gerontology Nurse Practitioner	F340839	NY

General Provider Information

NPI Number	:	1710395702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINO GVELESIANI MS, ANP-BC, GNP-BC

Provider Business Mailing Address
First Line	:	3802 FORT HAMILTON PARKWAY
Second Line	:	APT. #4
City	:	BROOKLYN
State	:	NY
Zip	:	11218-1971
Country	:	US
Telephone Number	:	718-436-7736
Fax Number	:

Provider Business Practice Location Address
First Line	:	3802 FORT HAMILTON PARKWAY
Second Line	:	APT. #4
City	:	BROOKLYN
State	:	NY
Zip	:	11218-1971
Country	:	US
Telephone Number	:	718-436-7736
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2014
Last Update Date	:	07/23/2014

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