Healthcare Provider Details

I. General information

NPI: 1851703516
Provider Name (Legal Business Name): INNA KUZNETSOV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 W BROADWAY AVE
ROBBINSDALE MN
55422-2207
US

IV. Provider business mailing address

8701 32ND AVE N
NEW HOPE MN
55427-2416
US

V. Phone/Fax

Practice location:
  • Phone: 612-332-4262
  • Fax:
Mailing address:
  • Phone: 612-207-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA30
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: