Provider Demographics
NPI:1073189759
Name:VASSALLO, ELIZABETH ANNE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:CLAYPOOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2466 FIELDSTONE RD SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-1378
Mailing Address - Country:US
Mailing Address - Phone:507-884-1984
Mailing Address - Fax:
Practice Address - Street 1:4461 WHITE BEAR PKWY STE 2
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7626
Practice Address - Country:US
Practice Address - Phone:651-348-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily