Provider Demographics
NPI:1700419884
Name:GLAZYNOVA, MAYA
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:GLAZYNOVA
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 1:3044 CONEY ISLAND AVE FL 8E3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5660
Mailing Address - Country:US
Mailing Address - Phone:718-265-4200
Mailing Address - Fax:718-265-8536
Practice Address - Street 1:3044 CONEY ISLAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5224
Practice Address - Country:US
Practice Address - Phone:718-265-4200
Practice Address - Fax:718-265-8536
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY517390163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01439087Medicaid