Provider Demographics
NPI:1578361069
Name:MITIANOVA, ANGELINA ALEKSEEVNA
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:ALEKSEEVNA
Last Name:MITIANOVA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:ALEKSEEVNA
Other - Last Name:SEMENOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:89 E DEDHAM ST APT 913
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3560
Mailing Address - Country:US
Mailing Address - Phone:305-440-8694
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:617-358-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program