Healthcare Provider Details

I. General information

NPI: 1467102061
Provider Name (Legal Business Name): TATJANA RADOSAVLJEVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5795 176 STREET
SURREY BC
V4A6X2
CA

IV. Provider business mailing address

5795 176 STREET
SURREY BC
V3S4E1
CA

V. Phone/Fax

Practice location:
  • Phone: 604-330-8989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number642111
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0919828
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: