Provider Demographics
NPI:1558091553
Name:NISANOV, AVIVA
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:
Last Name:NISANOV
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 1:13775 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1925
Mailing Address - Country:US
Mailing Address - Phone:917-449-2391
Mailing Address - Fax:
Practice Address - Street 1:11506 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2346
Practice Address - Country:US
Practice Address - Phone:917-254-0973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant