Provider Demographics
NPI:1629737143
Name:FOURNELLE, ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FOURNELLE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 WILLIAM TELL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5643
Mailing Address - Country:US
Mailing Address - Phone:651-315-0132
Mailing Address - Fax:
Practice Address - Street 1:721 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9118
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106717225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist