Provider Demographics
NPI:1003166174
Name:NIYAZOV, JULIE ALEXA
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ALEXA
Last Name:NIYAZOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-04 171 STREET
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366
Mailing Address - Country:US
Mailing Address - Phone:917-903-9616
Mailing Address - Fax:
Practice Address - Street 1:75-04 171 STREET
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366
Practice Address - Country:US
Practice Address - Phone:917-903-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659121121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist