Provider Demographics
NPI:1417559451
Name:IVANOVA, NINA
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:IVANOVA
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 1:6545 N LANDMARK DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5990
Mailing Address - Country:US
Mailing Address - Phone:435-647-9040
Mailing Address - Fax:435-647-9042
Practice Address - Street 1:6545 N LANDMARK DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5990
Practice Address - Country:US
Practice Address - Phone:435-647-9040
Practice Address - Fax:435-647-9042
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT292261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist