Provider Demographics
NPI:1013158609
Name:PITTMAN, CHANNA ROXANNE (RN)
Entity Type:Individual
Prefix:MRS
First Name:CHANNA
Middle Name:ROXANNE
Last Name:PITTMAN
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 1:1115 GREENBRIER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2540
Mailing Address - Country:US
Mailing Address - Phone:651-354-4228
Mailing Address - Fax:651-797-4413
Practice Address - Street 1:1115 GREENBRIER ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2540
Practice Address - Country:US
Practice Address - Phone:651-354-4228
Practice Address - Fax:651-797-4413
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR171403-6163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse