Provider Demographics
NPI:1073839924
Name:KSENDZOVSKAYA, TATYANA (NP)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:KSENDZOVSKAYA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4806
Mailing Address - Country:US
Mailing Address - Phone:917-767-7772
Mailing Address - Fax:718-648-9677
Practice Address - Street 1:2266 E 23RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4806
Practice Address - Country:US
Practice Address - Phone:917-767-7772
Practice Address - Fax:718-648-9677
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-18
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420983363LA2200X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty