Healthcare Provider Details

I. General information

NPI: 1982158366
Provider Name (Legal Business Name): MARINA KOLMANOVSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 DAHILL RD 2ND FLOOR
BROOKLYN NY
11204-3573
US

IV. Provider business mailing address

2547 W 2ND ST APT 3B
BROOKLYN NY
11223-6250
US

V. Phone/Fax

Practice location:
  • Phone: 718-375-2505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: