Provider Demographics
NPI:1699030296
Name:NIKOLOVA, MIRENA (NP)
Entity Type:Individual
Prefix:
First Name:MIRENA
Middle Name:
Last Name:NIKOLOVA
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 1:6225 WOODHAVEN BLVD APT 1B
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2709
Mailing Address - Country:US
Mailing Address - Phone:347-576-3131
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST # 326
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308782363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health