Provider Demographics
NPI:1649210311
Name:MITLYANSKY, NATALIE
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:
Last Name:MITLYANSKY
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 1:360 COLDSPRING RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3530
Mailing Address - Country:US
Mailing Address - Phone:215-942-4112
Mailing Address - Fax:215-223-2358
Practice Address - Street 1:2701 NORTH BROAD STREET
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132
Practice Address - Country:US
Practice Address - Phone:215-223-2356
Practice Address - Fax:215-223-2358
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU97399Medicare UPIN