Provider Demographics
NPI:1457013161
Name:CHMYROVA, TETYANA (AGNP-C)
Entity Type:Individual
Prefix:
First Name:TETYANA
Middle Name:
Last Name:CHMYROVA
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HOSPITAL DR STE 9
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-6434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:459 JACK MARTIN BLVD STE 5
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7724
Practice Address - Country:US
Practice Address - Phone:732-840-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182359363L00000X
NJ26NJ01407800363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner