Basic Information
Provider Information | |||||||||
NPI: | 1902883705 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHALL | ||||||||
FirstName: | JOY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6465 WAYZATA BLVD | ||||||||
Address2: | STE 315 | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554261728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529937169 | ||||||||
FaxNumber: | 9529930300 | ||||||||
Practice Location | |||||||||
Address1: | 300 LAKE DR E | ||||||||
Address2: | EPARK NICOLLET CLINIC - CHANHASSEN | ||||||||
City: | CHANHASSEN | ||||||||
State: | MN | ||||||||
PostalCode: | 553179302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529934300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | R 0764320 | MN | Y |   | Nursing Service Providers | Registered Nurse | Pediatrics |
No ID Information.