Provider Demographics
NPI:1629445176
Name:KHURSAND, AVESTA MIRIAM (NP)
Entity Type:Individual
Prefix:MRS
First Name:AVESTA
Middle Name:MIRIAM
Last Name:KHURSAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 THORNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3253
Mailing Address - Country:US
Mailing Address - Phone:516-316-4689
Mailing Address - Fax:925-281-2589
Practice Address - Street 1:32 THORNEY AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3253
Practice Address - Country:US
Practice Address - Phone:212-233-5032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401883363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health