Provider Demographics
NPI:1043774250
Name:VANRISSEGHEM, JAYME NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:JAYME
Middle Name:NICOLE
Last Name:VANRISSEGHEM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JAYME
Other - Middle Name:NICOLE
Other - Last Name:KINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-0311
Mailing Address - Country:US
Mailing Address - Phone:218-821-0610
Mailing Address - Fax:
Practice Address - Street 1:108 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3575
Practice Address - Country:US
Practice Address - Phone:218-829-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist