Healthcare Provider Details

I. General information

NPI: 1679016430
Provider Name (Legal Business Name): MARINA DZHURAYEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9966 65TH AVE
REGO PARK NY
11374-3653
US

IV. Provider business mailing address

9966 65TH AVE
REGO PARK NY
11374-3653
US

V. Phone/Fax

Practice location:
  • Phone: 347-527-8408
  • Fax:
Mailing address:
  • Phone: 347-527-8408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number642523121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: