MEDICARE: ELENA KOUZMINA APRN

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	163W00000X	Registered Nurse	937252	FL
2	363LG0600X	Gerontology Nurse Practitioner	11003036	FL
3	363LA2200X	Adult Health Nurse Practitioner	11003036	FL

General Provider Information

NPI Number	:	1700430279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELENA KOUZMINA APRN

Provider Business Mailing Address
First Line	:	831 CORAL RIDGE DR
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-4180
Country	:	US
Telephone Number	:	954-248-3422
Fax Number	:	800-970-6020

Provider Business Practice Location Address
First Line	:	130 JFK DR STE 138
Second Line	:
City	:	ATLANTIS
State	:	FL
Zip	:	33462-6631
Country	:	US
Telephone Number	:	954-248-3422
Fax Number	:	800-970-6020

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

Provider Enumeration Date	:	08/01/2019
Last Update Date	:	09/24/2019

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