Provider Demographics
NPI:1033877378
Name:ANTONOVA, KHRYSTYNA (NP)
Entity Type:Individual
Prefix:
First Name:KHRYSTYNA
Middle Name:
Last Name:ANTONOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15552 57TH PL N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3737
Mailing Address - Country:US
Mailing Address - Phone:612-481-1842
Mailing Address - Fax:
Practice Address - Street 1:15552 57TH PL N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3737
Practice Address - Country:US
Practice Address - Phone:612-481-1842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7317363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner