=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558091553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVIVA NISANOV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2022
-----------------------------------------------------
Last Update Date | 06/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11506 ROCKAWAY BEACH BLVD
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-2346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-254-0973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13775 70TH AVE
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11367-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-449-2391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------