Basic Information
| Provider Information | |||||||||
| NPI: | 1891166468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEMENOVA | ||||||||
| FirstName: | TATYANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDELWEISS | ||||||||
| OtherFirstName: | EDELWEISS | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | PROF. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2717 E 28TH ST APT 6E | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112352477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473329186 | ||||||||
| FaxNumber: | 7189758502 | ||||||||
| Practice Location | |||||||||
| Address1: | 2717 E 28TH ST | ||||||||
| Address2: | APT 6E | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112352477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473329186 | ||||||||
| FaxNumber: | 7189758502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F307141 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.