Healthcare Provider Details

I. General information

NPI: 1821594656
Provider Name (Legal Business Name): BRONWYN LISSA KNAEBE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 TOWN CENTRE DR STE 220
EAGAN MN
55123-1186
US

IV. Provider business mailing address

1185 TOWN CENTRE DR STE 220
EAGAN MN
55123-1186
US

V. Phone/Fax

Practice location:
  • Phone: 651-379-1600
  • Fax:
Mailing address:
  • Phone: 651-379-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number3968
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: