Provider Demographics
NPI:1437949625
Name:IEVTUSHENKO, GANNA
Entity type:Individual
Prefix:
First Name:GANNA
Middle Name:
Last Name:IEVTUSHENKO
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 1:28940 229TH PL SE
Mailing Address - Street 2:
Mailing Address - City:BLACK DIAMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98010-1250
Mailing Address - Country:US
Mailing Address - Phone:425-233-1611
Mailing Address - Fax:
Practice Address - Street 1:28940 229TH PL SE
Practice Address - Street 2:
Practice Address - City:BLACK DIAMOND
Practice Address - State:WA
Practice Address - Zip Code:98010-1250
Practice Address - Country:US
Practice Address - Phone:425-233-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC61678085376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide