Provider Demographics
NPI:1295111888
Name:MICO, BIANA KORJEVSKY (FNP-BC)
Entity type:Individual
Prefix:
First Name:BIANA
Middle Name:KORJEVSKY
Last Name:MICO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 BRUCEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 WORCESTER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5568
Practice Address - Country:US
Practice Address - Phone:617-219-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2278675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily