Provider Demographics
NPI:1972162089
Name:TKACHENKO, OLGA
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:TKACHENKO
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 1:3545 79TH ST APT 5E
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-4836
Mailing Address - Country:US
Mailing Address - Phone:347-350-4934
Mailing Address - Fax:
Practice Address - Street 1:224 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2168
Practice Address - Country:US
Practice Address - Phone:973-942-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY622678367500000X
NJ26NJ01293100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered