Provider Demographics
NPI:1356028047
Name:IGNATOV, LANA
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:IGNATOV
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 1:21 BRANTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4204
Mailing Address - Country:US
Mailing Address - Phone:917-557-1865
Mailing Address - Fax:
Practice Address - Street 1:20 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6434
Practice Address - Country:US
Practice Address - Phone:903-721-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028205363LP0808X
NJ26NJ15066300363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health