Healthcare Provider Details

I. General information

NPI: 1366130080
Provider Name (Legal Business Name): YELENA DZHURAYEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 04/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8832 69TH RD
FOREST HILLS NY
11375-6610
US

IV. Provider business mailing address

8832 69TH RD
FOREST HILLS NY
11375-6610
US

V. Phone/Fax

Practice location:
  • Phone: 917-583-1171
  • Fax:
Mailing address:
  • Phone: 917-583-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311020
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: