Provider Demographics
NPI:1881030658
Name:NAMBALLA, LAVANYA (MD)
Entity Type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:NAMBALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 STINSON BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1527 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-6700
Practice Address - Country:US
Practice Address - Phone:612-721-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17628207R00000X
MN65322207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
14137435OtherCAQH