Healthcare Provider Details

I. General information

NPI: 1689975559
Provider Name (Legal Business Name): MAZOL AMINOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 76TH ST
BROOKLYN NY
11228-2420
US

IV. Provider business mailing address

1314 76TH ST
BROOKLYN NY
11228-2420
US

V. Phone/Fax

Practice location:
  • Phone: 718-528-3432
  • Fax:
Mailing address:
  • Phone: 718-528-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number5979761
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: