Provider Demographics
NPI:1215491634
Name:IVANOVA, TAMARA S (NP)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:IVANOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3516
Mailing Address - Fax:757-686-0230
Practice Address - Street 1:612 KINGSBOROUGH SQ STE 100
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5041
Practice Address - Country:US
Practice Address - Phone:757-547-9294
Practice Address - Fax:757-213-9342
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5011406363LF0000X
VA0024181213363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily