Provider Demographics
NPI:1508612938
Name:SHANKULIE, AYANTU KAYO
Entity Type:Individual
Prefix:
First Name:AYANTU
Middle Name:KAYO
Last Name:SHANKULIE
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 1:111 KELLOGG BLVD E APT 1514
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1214
Mailing Address - Country:US
Mailing Address - Phone:651-421-5221
Mailing Address - Fax:
Practice Address - Street 1:1001 E 77TH ST APT 305
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4551
Practice Address - Country:US
Practice Address - Phone:651-421-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician