Healthcare Provider Details

I. General information

NPI: 1275293540
Provider Name (Legal Business Name): MARIYA A KOVALEVA RN, PHD, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 S 38TH AVE
OMAHA NE
68105-1107
US

IV. Provider business mailing address

985330 NEBRASKA MEDICAL CTR OFC 50113
OMAHA NE
68198-5330
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-9600
  • Fax:
Mailing address:
  • Phone: 402-559-6548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number92715
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number113558
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number113558
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: