Healthcare Provider Details

I. General information

NPI: 1699520304
Provider Name (Legal Business Name): IRENA HOVHANNISYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3974 AMBOY RD STE 302
STATEN ISLAND NY
10308-2414
US

IV. Provider business mailing address

52 EAGAN AVE
STATEN ISLAND NY
10312-4104
US

V. Phone/Fax

Practice location:
  • Phone: 718-967-1071
  • Fax:
Mailing address:
  • Phone: 646-406-9286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF353707
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: