Healthcare Provider Details

I. General information

NPI: 1477229144
Provider Name (Legal Business Name): IDA JIVOTOVSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2021
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HIGH RIDGE RD STE 3
STAMFORD CT
06905-1202
US

IV. Provider business mailing address

51 DENNIS LN
PLEASANTVILLE NY
10570-1032
US

V. Phone/Fax

Practice location:
  • Phone: 465-813-2176
  • Fax:
Mailing address:
  • Phone: 631-316-4553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9884
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: