Provider Demographics
NPI:1669583480
Name:GANKIN, INESSA (ANP)
Entity type:Individual
Prefix:
First Name:INESSA
Middle Name:
Last Name:GANKIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28701 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150
Mailing Address - Country:US
Mailing Address - Phone:734-427-9900
Mailing Address - Fax:734-427-8963
Practice Address - Street 1:28701 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150
Practice Address - Country:US
Practice Address - Phone:734-427-9900
Practice Address - Fax:734-427-8963
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704226176363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC00882OtherMEDICARE RAILROAD PIN
MI0N73140Medicare PIN