Provider Demographics
NPI:1477375418
Name:SHMAVONYAN, IRENA (MSED)
Entity type:Individual
Prefix:
First Name:IRENA
Middle Name:
Last Name:SHMAVONYAN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 OCEAN AVE APT 4R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3355
Mailing Address - Country:US
Mailing Address - Phone:347-445-7575
Mailing Address - Fax:
Practice Address - Street 1:3060 OCEAN AVE APT 4R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3355
Practice Address - Country:US
Practice Address - Phone:347-445-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1856769241390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty