Healthcare Provider Details

I. General information

NPI: 1700419884
Provider Name (Legal Business Name): MAYA GLAZYNOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3044 CONEY ISLAND AVE STE 3
BROOKLYN NY
11235-5224
US

IV. Provider business mailing address

3044 CONEY ISLAND AVE FL 8E3
BROOKLYN NY
11235-5660
US

V. Phone/Fax

Practice location:
  • Phone: 718-265-4200
  • Fax: 718-265-8536
Mailing address:
  • Phone: 718-265-4200
  • Fax: 718-265-8536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number517390
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: