Healthcare Provider Details

I. General information

NPI: 1568747038
Provider Name (Legal Business Name): OLGA N GAVRILENKO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6674 WESTON CIR W
DUBLIN OH
43016-7901
US

IV. Provider business mailing address

1091 KEMPTON RUN DR
COLUMBUS OH
43235-3508
US

V. Phone/Fax

Practice location:
  • Phone: 614-595-1055
  • Fax: 614-873-2040
Mailing address:
  • Phone: 614-506-9378
  • Fax: 614-844-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.12424-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: