Provider Demographics
NPI:1386250959
Name:NELSON, CHESSIE LEE
Entity type:Individual
Prefix:
First Name:CHESSIE
Middle Name:LEE
Last Name:NELSON
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 1:1110 80TH AVE NE APT 5
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1354
Mailing Address - Country:US
Mailing Address - Phone:612-986-6987
Mailing Address - Fax:
Practice Address - Street 1:550 VANDALIA ST STE 175
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-2019
Practice Address - Country:US
Practice Address - Phone:651-313-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician