Healthcare Provider Details

I. General information

NPI: 1316853815
Provider Name (Legal Business Name): IGOR PAVLENKO CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16153 ENCHANTED PEAK WAY
MONUMENT CO
80132-6164
US

IV. Provider business mailing address

16153 ENCHANTED PEAK WAY
MONUMENT CO
80132-6164
US

V. Phone/Fax

Practice location:
  • Phone: 860-670-9978
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNA.00836873
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: