Healthcare Provider Details

I. General information

NPI: 1285487835
Provider Name (Legal Business Name): NATALI N/A GAVRIELOV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5913 RUE VILLA LN
TUCKER GA
30084-1964
US

IV. Provider business mailing address

5913 RUE VILLA LN
TUCKER GA
30084-1964
US

V. Phone/Fax

Practice location:
  • Phone: 770-846-5718
  • Fax:
Mailing address:
  • Phone: 770-846-5718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPRN-NP290310
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN290310
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: