Provider Demographics
NPI:1740697960
Name:MIRONOVA, EKATERINA (AG-ACNP)
Entity type:Individual
Prefix:MS
First Name:EKATERINA
Middle Name:
Last Name:MIRONOVA
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BUTTRICK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3417
Mailing Address - Country:US
Mailing Address - Phone:603-537-1300
Mailing Address - Fax:
Practice Address - Street 1:15 TSIENNETO RD
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1557
Practice Address - Country:US
Practice Address - Phone:603-537-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2329856363LA2100X
AZTAP5715363LA2100X
NH087881-23363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care