Provider Demographics
NPI:1013201557
Name:POLVANOVA, STELLA (NP)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:POLVANOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3645
Mailing Address - Country:US
Mailing Address - Phone:718-327-7307
Mailing Address - Fax:718-327-3294
Practice Address - Street 1:529 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3645
Practice Address - Country:US
Practice Address - Phone:718-327-7307
Practice Address - Fax:718-327-3294
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY486629-1163W00000X
NYF305534-1363LA2200X
NYF340789-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology