=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952493132
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILIA NIKOLAYEV M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 03/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 96 WILLARD ST SUITE 306
-----------------------------------------------------
City | COCOA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32922-7991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-638-0027
-----------------------------------------------------
Fax | 321-638-0115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1438 TIPPERARY DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-6032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-806-4551
-----------------------------------------------------
Fax | 321-638-0115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME97734
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------