Provider Demographics
NPI:1164927695
Name:SLAVOVA, EMILIA IVANOVA (FNP-BC)
Entity type:Individual
Prefix:
First Name:EMILIA
Middle Name:IVANOVA
Last Name:SLAVOVA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447
Mailing Address - Country:US
Mailing Address - Phone:570-580-4171
Mailing Address - Fax:866-600-7413
Practice Address - Street 1:1619 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447
Practice Address - Country:US
Practice Address - Phone:570-580-4171
Practice Address - Fax:866-600-7413
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017996363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014816520001Medicaid