Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | F305534-1 | NY |
N | 363LG0600X | Nurse Practitioner - Gerontology | F340789-1 | NY |
NPI | 1013201557 |
---|---|
Provider Name | Stella Polvanova |
First Address | Far Rockaway, NY 11691-3645 |
Second Address | Far Rockaway, NY 11691-3645 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2011 |
Last Update Date | 01/06/2011 |