Healthcare Provider Details

I. General information

NPI: 1164245908
Provider Name (Legal Business Name): KSENIYA TARASOVA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12201 RESEARCH PKWY STE 300
ORLANDO FL
32826-3265
US

IV. Provider business mailing address

PO BOX 84
WINTER PARK FL
32790-0084
US

V. Phone/Fax

Practice location:
  • Phone: 407-823-2744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11035785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: