Healthcare Provider Details

I. General information

NPI: 1811458839
Provider Name (Legal Business Name): KSENYA TVERITINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 MAIN ST APT 211
SANTA MONICA CA
90405-7202
US

IV. Provider business mailing address

2209 MAIN ST APT 211
SANTA MONICA CA
90405-7202
US

V. Phone/Fax

Practice location:
  • Phone: 323-352-4606
  • Fax:
Mailing address:
  • Phone: 323-352-4606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number19612045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: