Healthcare Provider Details

I. General information

NPI: 1164844304
Provider Name (Legal Business Name): MICHELLE MEZERA RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 FRANCE AVE S STE 202
EDINA MN
55435-4551
US

IV. Provider business mailing address

PO BOX 206
MINNEAPOLIS MN
55480-0206
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-1311
  • Fax: 952-428-0099
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2940
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: