Provider Demographics
NPI:1225492739
Name:SWANSTROM, BRIELLE JOY (MD)
Entity Type:Individual
Prefix:
First Name:BRIELLE
Middle Name:JOY
Last Name:SWANSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRIELLE
Other - Middle Name:JOY
Other - Last Name:HAGGERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14000 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4571
Mailing Address - Country:US
Mailing Address - Phone:952-993-8700
Mailing Address - Fax:952-993-8516
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-993-8700
Practice Address - Fax:952-993-8516
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN62529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics