Provider Demographics
NPI:1730510918
Name:MAMIKONYAN, SVETLANA (CRNP)
Entity type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:MAMIKONYAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SVETLANA
Other - Middle Name:
Other - Last Name:SAKHNOVSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:1648 HUNTINGDON PIKE
Mailing Address - Street 2:MEDICAL STAFF OFFICE 1ST FLR
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8001
Mailing Address - Country:US
Mailing Address - Phone:215-938-3450
Mailing Address - Fax:215-938-3829
Practice Address - Street 1:3300 TILLMAN DR
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2071
Practice Address - Country:US
Practice Address - Phone:215-914-4444
Practice Address - Fax:215-245-2073
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner