Healthcare Provider Details

I. General information

NPI: 1841741725
Provider Name (Legal Business Name): NATALYA DIZENGOF R.N., F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BROAD ST 21ST FL.
NEW YORK NY
10004-2501
US

IV. Provider business mailing address

55 BROAD ST 21ST FL.
NEW YORK NY
10004-2501
US

V. Phone/Fax

Practice location:
  • Phone: 708-628-7667
  • Fax:
Mailing address:
  • Phone: 708-628-7667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number612141-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340393-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: