Provider Demographics
NPI:1891461224
Name:VAILLANCOURT, CHARITY JOY (RN)
Entity Type:Individual
Prefix:MRS
First Name:CHARITY
Middle Name:JOY
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7740 HADLEY AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-2651
Mailing Address - Country:US
Mailing Address - Phone:612-224-0528
Mailing Address - Fax:
Practice Address - Street 1:7740 HADLEY AVE S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-2651
Practice Address - Country:US
Practice Address - Phone:612-224-0528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2460565163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice