Healthcare Provider Details

I. General information

NPI: 1053139766
Provider Name (Legal Business Name): OLGA TIKHONOV RN, IBCLC, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 N WILLOW ST APT 1
MONTCLAIR NJ
07042-3502
US

IV. Provider business mailing address

48 N WILLOW ST APT 1
MONTCLAIR NJ
07042-3502
US

V. Phone/Fax

Practice location:
  • Phone: 201-925-5276
  • Fax:
Mailing address:
  • Phone: 201-925-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-141081
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: