Provider Demographics
NPI:1760731533
Name:ROBENOV, KSENIYA (AGNP, RN)
Entity Type:Individual
Prefix:MRS
First Name:KSENIYA
Middle Name:
Last Name:ROBENOV
Suffix:
Gender:F
Credentials:AGNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147-56 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147-56 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435
Practice Address - Country:US
Practice Address - Phone:347-730-1198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY646394163W00000X
NY308122363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse