Healthcare Provider Details

I. General information

NPI: 1699093021
Provider Name (Legal Business Name): KRYSTLE E LIEBERMAN WALL DC, RD, LD, CBS LC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTLE E LIEBERMAN DC, RD, LD

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 DULUTH ST SUITE 150
GOLDEN VALLEY MN
55422-3958
US

IV. Provider business mailing address

5801 DULUTH ST SUITE 150
GOLDEN VALLEY MN
55422-3958
US

V. Phone/Fax

Practice location:
  • Phone: 736-541-1280
  • Fax: 763-541-1012
Mailing address:
  • Phone: 736-541-1280
  • Fax: 763-541-1012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2716
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number876
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5317
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: