MEDICARE: TATYANA KSENDZOVSKAYA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	420983	NY
2	261QM2500X	Medical Specialty Clinic/Center	420983	NY

General Provider Information

NPI Number	:	1073839924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATYANA KSENDZOVSKAYA NP

Provider Business Mailing Address
First Line	:	2266 E 23RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4806
Country	:	US
Telephone Number	:	917-767-7772
Fax Number	:	718-648-9677

Provider Business Practice Location Address
First Line	:	2266 E 23RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4806
Country	:	US
Telephone Number	:	917-767-7772
Fax Number	:	718-648-9677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2010
Last Update Date	:	03/24/2021

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