Healthcare Provider Details

I. General information

NPI: 1558663674
Provider Name (Legal Business Name): TATYANA REZNIK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9876
  • Fax: 914-709-8165
Mailing address:
  • Phone: 212-305-9876
  • Fax: 914-709-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN181059
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number639539-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number639539
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: