Healthcare Provider Details

I. General information

NPI: 1669095196
Provider Name (Legal Business Name): KSENIYA DOR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6433 99TH ST APT 6L
REGO PARK NY
11374-3543
US

IV. Provider business mailing address

6433 99TH ST APT 6L
REGO PARK NY
11374-3543
US

V. Phone/Fax

Practice location:
  • Phone: 929-255-0911
  • Fax:
Mailing address:
  • Phone: 929-255-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF309554
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: