Healthcare Provider Details

I. General information

NPI: 1700430279
Provider Name (Legal Business Name): ELENA KOUZMINA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 JFK DR STE 138
ATLANTIS FL
33462-6631
US

IV. Provider business mailing address

831 CORAL RIDGE DR
CORAL SPRINGS FL
33071-4180
US

V. Phone/Fax

Practice location:
  • Phone: 954-248-3422
  • Fax: 800-970-6020
Mailing address:
  • Phone: 954-248-3422
  • Fax: 800-970-6020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11003036
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11003036
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number937252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: