Healthcare Provider Details

I. General information

NPI: 1609559400
Provider Name (Legal Business Name): ELENA TIOUTIAREVA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 W UNDERWOOD ST
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

1714 MAGNOLIA AVE
SOUTH DAYTONA FL
32119-1711
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5112
  • Fax:
Mailing address:
  • Phone: 407-242-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11027673
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAPRN11027673
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: