Healthcare Provider Details

I. General information

NPI: 1619408564
Provider Name (Legal Business Name): IRINA MIRONOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

1830 GRAMERCY PL
HUMMELSTOWN PA
17036-7041
US

V. Phone/Fax

Practice location:
  • Phone: 347-277-3300
  • Fax:
Mailing address:
  • Phone: 347-277-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: