MEDICARE: OLGA KOSICHENKO PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F405558-01	NY

General Provider Information

NPI Number	:	1912765520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLGA KOSICHENKO PMHNP

Provider Business Mailing Address
First Line	:	29 HOMER ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-3101
Country	:	US
Telephone Number	:	646-643-4492
Fax Number	:

Provider Business Practice Location Address
First Line	:	29 HOMER ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-3101
Country	:	US
Telephone Number	:	646-643-4492
Fax Number	:

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

Provider Enumeration Date	:	03/08/2024
Last Update Date	:	03/08/2024

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