Healthcare Provider Details

I. General information

NPI: 1881555712
Provider Name (Legal Business Name): MARINA MIRONOVA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 TIMBER RIDGE DR
STATEN ISLAND NY
10306-6124
US

IV. Provider business mailing address

292 TIMBER RIDGE DR
STATEN ISLAND NY
10306-6124
US

V. Phone/Fax

Practice location:
  • Phone: 347-603-5647
  • Fax: 347-695-1117
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF311058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: