Provider Demographics
NPI:1659119220
Name:TAKHTAROV, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:TAKHTAROV
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 1:141 ROUTE 70 E STE B
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 ROUTE 70 E STE B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1855
Practice Address - Country:US
Practice Address - Phone:856-596-9057
Practice Address - Fax:856-596-0837
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15114400363LA2200X
NJ26NR26058900163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1028596Medicaid