Healthcare Provider Details

I. General information

NPI: 1194931113
Provider Name (Legal Business Name): AMY SUE CORUM R.D., L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 NININGER RD
HASTINGS MN
55033-1056
US

IV. Provider business mailing address

15630 UPPER 194TH ST E
HASTINGS MN
55033-9685
US

V. Phone/Fax

Practice location:
  • Phone: 651-480-4100
  • Fax: 651-480-4212
Mailing address:
  • Phone: 651-438-3348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1857
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: