Provider Demographics
NPI:1477730331
Name:ESTANISLAO, MYLEN
Entity Type:Individual
Prefix:
First Name:MYLEN
Middle Name:
Last Name:ESTANISLAO
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 1:215 EUCLID AVENUE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-869-2707
Mailing Address - Fax:201-869-2717
Practice Address - Street 1:9225 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5361
Practice Address - Country:US
Practice Address - Phone:201-869-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01125900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist