Provider Demographics
NPI:1922373489
Name:KOLESNIKOVA, TATYANA (RN, NP)
Entity Type:Individual
Prefix:MS
First Name:TATYANA
Middle Name:
Last Name:KOLESNIKOVA
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:MS
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:CHAIMOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1623 KINGS HWY
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1209
Mailing Address - Country:US
Mailing Address - Phone:718-375-1200
Mailing Address - Fax:
Practice Address - Street 1:1623 KINGS HWY
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1209
Practice Address - Country:US
Practice Address - Phone:718-375-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305972-1363LA2200X
NYF340835-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health