Healthcare Provider Details

I. General information

NPI: 1073839924
Provider Name (Legal Business Name): TATYANA KSENDZOVSKAYA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2010
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 E 23RD ST
BROOKLYN NY
11229-4806
US

IV. Provider business mailing address

2266 E 23RD ST
BROOKLYN NY
11229-4806
US

V. Phone/Fax

Practice location:
  • Phone: 917-767-7772
  • Fax: 718-648-9677
Mailing address:
  • Phone: 917-767-7772
  • Fax: 718-648-9677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number420983
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number420983
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: