Basic Information
| Provider Information | |||||||||
| NPI: | 1316478217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEREZANSKAYA | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1095 NW SAINT LUCIE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349861719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727855511 | ||||||||
| FaxNumber: | 7727855531 | ||||||||
| Practice Location | |||||||||
| Address1: | 1095 NW SAINT LUCIE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349861719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727855511 | ||||||||
| FaxNumber: | 7727855531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2017 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | OS17802 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | OS17802 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.