Provider Demographics
NPI:1003564014
Name:JILKEVORKIAN, TANYA RITA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:RITA
Last Name:JILKEVORKIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 WEKIVA SPRINGS RD STE 231
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3690
Mailing Address - Country:US
Mailing Address - Phone:626-433-7014
Mailing Address - Fax:
Practice Address - Street 1:365 WEKIVA SPRINGS RD STE 231
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-3690
Practice Address - Country:US
Practice Address - Phone:626-433-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020371363L00000X
AZ247800363L00000X
NV855699363L00000X
FL11018902363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner