Healthcare Provider Details

I. General information

NPI: 1366962862
Provider Name (Legal Business Name): CHARLOTTE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W STE 325S
SAINT PAUL MN
55114-1903
US

IV. Provider business mailing address

2550 UNIVERSITY AVE W STE 325S
SAINT PAUL MN
55114-1903
US

V. Phone/Fax

Practice location:
  • Phone: 888-709-9344
  • Fax: 888-990-2714
Mailing address:
  • Phone: 888-709-9344
  • Fax: 888-990-2714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: