Healthcare Provider Details

I. General information

NPI: 1255540498
Provider Name (Legal Business Name): VANESSA R HUMPHREVILLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

24701 EUCLID AVE 3RD FLOOR
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number53909
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number53909
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: