Healthcare Provider Details

I. General information

NPI: 1962310870
Provider Name (Legal Business Name): AVITAL KOENOV
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 WARWICK RD
HEWLETT NY
11557-1832
US

IV. Provider business mailing address

1657 WARWICK RD
HEWLETT NY
11557-1832
US

V. Phone/Fax

Practice location:
  • Phone: 718-581-3906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN51518
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: