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General NPI Number Information
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NPI Number | 1013140805
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Entity Type | Organization
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Legal Business Name | 817 MARSHALL AVE
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/27/2009
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Provider Practice Location Address
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Address Line | 817 MARSHALL AVE
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City | SAINT PAUL
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State | MN
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Zip | 55104-6651
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Country | US
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Telephone | 763-202-8808
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Fax | 651-291-2739
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Provider Business Mailing Address
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Address Line | 817 MARSHALL AVE
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City | SAINT PAUL
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State | MN
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Zip | 55104-6651
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Country | US
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Telephone | 763-202-8808
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Fax | 651-291-2739
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Authorized Official
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Title or Position | PRIVTE DUTY NURSE
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Name | MRS. CHANNA ROXANNE PITTMAN
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Credential | RN
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Telephone | 763-202-8808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | R171403-6
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License Number State | MN
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