Provider Demographics
NPI:1255838876
Name:MIRRA, REGINA ANN
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:ANN
Last Name:MIRRA
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 1:74 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-4428
Mailing Address - Country:US
Mailing Address - Phone:914-815-3189
Mailing Address - Fax:
Practice Address - Street 1:501 CHESTNUT RIDGE RD STE 205
Practice Address - Street 2:
Practice Address - City:CHESTNUT RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10977-5669
Practice Address - Country:US
Practice Address - Phone:845-738-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135687861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist