Healthcare Provider Details

I. General information

NPI: 1659758621
Provider Name (Legal Business Name): NP ADULT HEALTH & GERONTOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 CORBIN PL
BROOKLYN NY
11235-4811
US

IV. Provider business mailing address

126 CORBIN PL
BROOKLYN NY
11235-4811
US

V. Phone/Fax

Practice location:
  • Phone: 347-729-5904
  • Fax:
Mailing address:
  • Phone: 347-729-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number569215-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF306361-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF340890-1
License Number StateNY

VIII. Authorized Official

Name: MS. ALINA BOSHAKOVA
Title or Position: NP
Credential:
Phone: 347-729-5904