Healthcare Provider Details

I. General information

NPI: 1215491634
Provider Name (Legal Business Name): TAMARA S IVANOVA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 KINGSBOROUGH SQ STE 100
CHESAPEAKE VA
23320-5041
US

IV. Provider business mailing address

PO BOX 7068
PORTSMOUTH VA
23707-0068
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-9294
  • Fax: 757-213-9342
Mailing address:
  • Phone: 757-686-3516
  • Fax: 757-686-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5011406
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024181213
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: