Provider Demographics
NPI:1902365984
Name:SKOMOROCHOW, EWELINA
Entity Type:Individual
Prefix:
First Name:EWELINA
Middle Name:
Last Name:SKOMOROCHOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 EMANUEL CLEAVER II BLVD APT 603
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-1721
Mailing Address - Country:US
Mailing Address - Phone:212-945-8516
Mailing Address - Fax:
Practice Address - Street 1:1800 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7521
Practice Address - Country:US
Practice Address - Phone:772-398-3623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program