Provider Demographics
NPI:1609559400
Name:TIOUTIAREVA, ELENA (APRN)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:TIOUTIAREVA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1711
Mailing Address - Country:US
Mailing Address - Phone:407-242-5364
Mailing Address - Fax:
Practice Address - Street 1:52 W UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-841-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027673363LA2100X
FLAPRN11027673363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care