Provider Demographics
NPI:1932674686
Name:VERNIKOV, ANATOLIY
Entity Type:Individual
Prefix:
First Name:ANATOLIY
Middle Name:
Last Name:VERNIKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-3978
Mailing Address - Country:US
Mailing Address - Phone:917-624-4040
Mailing Address - Fax:
Practice Address - Street 1:1463 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-3978
Practice Address - Country:US
Practice Address - Phone:917-624-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302471-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty