Provider Demographics
NPI:1891166468
Name:SEMENOVA, TATYANA (NP)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:SEMENOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:PROF
Other - First Name:EDELWEISS
Other - Middle Name:
Other - Last Name:EDELWEISS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2717 E 28TH ST APT 6E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2477
Mailing Address - Country:US
Mailing Address - Phone:347-332-9186
Mailing Address - Fax:718-975-8502
Practice Address - Street 1:2717 E 28TH ST
Practice Address - Street 2:APT 6E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2477
Practice Address - Country:US
Practice Address - Phone:347-332-9186
Practice Address - Fax:718-975-8502
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307141363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health