Provider Demographics
NPI:1801563259
Name:CHABANOV, NINA (SE)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:CHABANOV
Suffix:
Gender:F
Credentials:SE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 AVENUE T APT A3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3306
Mailing Address - Country:US
Mailing Address - Phone:347-401-2677
Mailing Address - Fax:
Practice Address - Street 1:704 AVENUE X FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6121
Practice Address - Country:US
Practice Address - Phone:347-307-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1118697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist