Provider Demographics
NPI:1225392814
Name:ZIVICA, DANA BETH (MST)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:BETH
Last Name:ZIVICA
Suffix:
Gender:F
Credentials:MST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BROADVIEW RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-6002
Mailing Address - Country:US
Mailing Address - Phone:917-596-8209
Mailing Address - Fax:
Practice Address - Street 1:14 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6002
Practice Address - Country:US
Practice Address - Phone:917-596-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY825579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist