Provider Demographics
NPI:1568213510
Name:MIMINOSHVILI, NINO
Entity Type:Individual
Prefix:MRS
First Name:NINO
Middle Name:
Last Name:MIMINOSHVILI
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 1:132 REINMAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5740
Mailing Address - Country:US
Mailing Address - Phone:347-524-3182
Mailing Address - Fax:
Practice Address - Street 1:132 REINMAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5740
Practice Address - Country:US
Practice Address - Phone:347-524-3182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF351425-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily