Provider Demographics
NPI:1972765972
Name:AYANA, ETYANE
Entity Type:Individual
Prefix:
First Name:ETYANE
Middle Name:
Last Name:AYANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20787 GEMINI TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-2515
Mailing Address - Country:US
Mailing Address - Phone:952-217-3635
Mailing Address - Fax:952-236-0138
Practice Address - Street 1:17305 CEDAR AVE S STE 220
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-3903
Practice Address - Country:US
Practice Address - Phone:952-465-1959
Practice Address - Fax:952-236-0138
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR178274-1163W00000X
MNF12220253363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse