Healthcare Provider Details

I. General information

NPI: 1538539549
Provider Name (Legal Business Name): TATSIANA SIANIUTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11880 BUSTLETON AVE STE 201
PHILADELPHIA PA
19116-2538
US

IV. Provider business mailing address

11880 BUSTLETON AVE STE 201
PHILADELPHIA PA
19116-2538
US

V. Phone/Fax

Practice location:
  • Phone: 267-357-5247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number20120677543-0615
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: