Provider Demographics
NPI:1639574841
Name:KAVTARADZE, NINO (CRNP)
Entity Type:Individual
Prefix:
First Name:NINO
Middle Name:
Last Name:KAVTARADZE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 BUSTLETON PIKE STE 16A3
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4118
Mailing Address - Country:US
Mailing Address - Phone:267-223-7738
Mailing Address - Fax:267-223-7738
Practice Address - Street 1:1200 BUSTLETON PIKE STE 16A3
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4118
Practice Address - Country:US
Practice Address - Phone:267-574-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN632493163W00000X
PASP015632363LF0000X, 363L00000X
PA26183601376K00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032670520017Medicaid
PASP015632OtherPENNSYLVANIA DEPARTMENT OF STATE
PARN632493OtherPENNSYLVANIA DEPARTMENT OF STATE
33402683OtherAMERICAN NURSES CREDENTIALING CENTER (ANCC)