Provider Demographics
NPI:1710382551
Name:KHESIN-SHPOLYANSKY, KSENIYA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KSENIYA
Middle Name:
Last Name:KHESIN-SHPOLYANSKY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:XENIA
Other - Middle Name:
Other - Last Name:KHESIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:14777 LOS GATOS BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2059
Mailing Address - Country:US
Mailing Address - Phone:408-340-5120
Mailing Address - Fax:650-421-7494
Practice Address - Street 1:14777 LOS GATOS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2059
Practice Address - Country:US
Practice Address - Phone:408-340-5120
Practice Address - Fax:650-421-7494
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000936363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily