Healthcare Provider Details

I. General information

NPI: 1336060557
Provider Name (Legal Business Name): IANA PANOVKINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 S 6TH ST
MINNEAPOLIS MN
55454-1336
US

IV. Provider business mailing address

2312 S 6TH ST F102-50, WEST BUILDING
MINNEAPOLIS MN
55454
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-4555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License Number684
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: