Provider Demographics
NPI:1265241459
Name:ICTCHENKO, ANNA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ICTCHENKO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 MOTOR RD
Mailing Address - Street 2:
Mailing Address - City:PINE BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:08741-1533
Mailing Address - Country:US
Mailing Address - Phone:718-300-4049
Mailing Address - Fax:
Practice Address - Street 1:906 MOTOR RD
Practice Address - Street 2:
Practice Address - City:PINE BEACH
Practice Address - State:NJ
Practice Address - Zip Code:08741-1533
Practice Address - Country:US
Practice Address - Phone:718-300-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192216363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health