Healthcare Provider Details

I. General information

NPI: 1043693401
Provider Name (Legal Business Name): TETYANA DATSYUK LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9113 IRISH GOLD WAY
SACRAMENTO CA
95826-5073
US

IV. Provider business mailing address

9113 IRISH GOLD WAY
SACRAMENTO CA
95826-5073
US

V. Phone/Fax

Practice location:
  • Phone: 916-588-7302
  • Fax:
Mailing address:
  • Phone: 916-588-7302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN280321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: