Healthcare Provider Details

I. General information

NPI: 1154965721
Provider Name (Legal Business Name): LANSA DAWANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 104TH TRL N
MINNEAPOLIS MN
55443-1012
US

IV. Provider business mailing address

3707 104TH TRL N
MINNEAPOLIS MN
55443-1012
US

V. Phone/Fax

Practice location:
  • Phone: 612-221-3554
  • Fax:
Mailing address:
  • Phone: 612-221-3554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number1098517
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: