Provider Demographics
NPI:1952976896
Name:MIJALSKI, SVETIANA
Entity Type:Individual
Prefix:
First Name:SVETIANA
Middle Name:
Last Name:MIJALSKI
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 1:17313 N 19TH TER
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-8100
Mailing Address - Country:US
Mailing Address - Phone:602-290-3584
Mailing Address - Fax:
Practice Address - Street 1:9326 W LOUISE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2960
Practice Address - Country:US
Practice Address - Phone:602-290-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL114G1H376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ123456789Medicaid