Provider Demographics
NPI:1174963805
Name:YAKOVLEFF, MISHA BORIS (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:MISHA
Middle Name:BORIS
Last Name:YAKOVLEFF
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03603-5006
Mailing Address - Country:US
Mailing Address - Phone:603-826-3704
Mailing Address - Fax:
Practice Address - Street 1:28 ELM ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:NH
Practice Address - Zip Code:03603-5006
Practice Address - Country:US
Practice Address - Phone:603-826-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH064902-21163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH064902-21OtherREGISTERED NURSE