Provider Demographics
NPI:1003645706
Name:MIRMALEK, SEYEDEH PEGAH
Entity type:Individual
Prefix:
First Name:SEYEDEH PEGAH
Middle Name:
Last Name:MIRMALEK
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 1:16 RAVENWOOD RD, 06107
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107
Mailing Address - Country:US
Mailing Address - Phone:860-503-6925
Mailing Address - Fax:
Practice Address - Street 1:FARMINGTON
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030
Practice Address - Country:US
Practice Address - Phone:860-503-6925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14209390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program