Healthcare Provider Details

I. General information

NPI: 1215976360
Provider Name (Legal Business Name): KATIE MARIE STOTERAU RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KATIE MARIE HUBER RD

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 YANKEE DOODLE RD
EAGAN MN
55121-2092
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-3970
  • Fax: 651-905-5087
Mailing address:
  • Phone: 612-262-4813
  • Fax: 612-262-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2180
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: