Healthcare Provider Details

I. General information

NPI: 1265141030
Provider Name (Legal Business Name): ATHINA NICOLAOU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ATHINA SALANDRA

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/21/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 30TH AVE
ASTORIA NY
11103-4366
US

IV. Provider business mailing address

64 77TH ST
BROOKLYN NY
11209-2919
US

V. Phone/Fax

Practice location:
  • Phone: 718-675-3800
  • Fax:
Mailing address:
  • Phone: 718-614-4128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349245
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number745476
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: