Provider Demographics
NPI:1821352030
Name:AMINOVA, ELEONORA I (MAED)
Entity Type:Individual
Prefix:MRS
First Name:ELEONORA
Middle Name:
Last Name:AMINOVA
Suffix:I
Gender:F
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8911 63RD DR
Mailing Address - Street 2:APT# 305 REGO PARK NY
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3852
Mailing Address - Country:US
Mailing Address - Phone:347-361-1394
Mailing Address - Fax:
Practice Address - Street 1:8911 63RD DR
Practice Address - Street 2:305
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3852
Practice Address - Country:US
Practice Address - Phone:347-361-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY557481111252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY557481111Medicaid