=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679016430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARINA DZHURAYEVA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2016
-----------------------------------------------------
Last Update Date | 11/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9966 65TH AVE
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-3653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-527-8408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9966 65TH AVE
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-3653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-527-8408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number | 642523121
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------