MEDICARE: NATALI N/A GAVRIELOV

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	163WN0002X	Neonatal Intensive Care Registered Nurse	RN290310	GA
2	363LN0005X	Critical Care Neonatal Nurse Practitioner	APRN-NP290310	GA

General Provider Information

NPI Number	:	1285487835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATALI N/A GAVRIELOV

Provider Business Mailing Address
First Line	:	5913 RUE VILLA LN
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-1964
Country	:	US
Telephone Number	:	770-846-5718
Fax Number	:

Provider Business Practice Location Address
First Line	:	5913 RUE VILLA LN
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-1964
Country	:	US
Telephone Number	:	770-846-5718
Fax Number	:

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

Provider Enumeration Date	:	04/11/2024
Last Update Date	:	01/05/2026

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