Healthcare Provider Details

I. General information

NPI: 1891319943
Provider Name (Legal Business Name): GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

IV. Provider business mailing address

200 UNIVERSITY AVE E # 455105
SAINT PAUL MN
55101-2507
US

V. Phone/Fax

Practice location:
  • Phone: 651-726-2890
  • Fax: 651-726-2848
Mailing address:
  • Phone: 651-325-2209
  • Fax: 651-325-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: VANESSA HARTZLER
Title or Position: MANAGER
Credential:
Phone: 651-325-2209