Provider Demographics
NPI:1275254377
Name:BRICHETTO, DEVON ELISABETH
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:ELISABETH
Last Name:BRICHETTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 COUNTY ROAD E E
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4612
Mailing Address - Country:US
Mailing Address - Phone:616-987-6458
Mailing Address - Fax:
Practice Address - Street 1:700 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9232
Practice Address - Country:US
Practice Address - Phone:651-714-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program