Healthcare Provider Details

I. General information

NPI: 1083213375
Provider Name (Legal Business Name): SUZANNA STEEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 COUNTY ROAD 90
INDEPENDENCE MN
55359-9764
US

IV. Provider business mailing address

2680 COUNTY ROAD 90
INDEPENDENCE MN
55359-9764
US

V. Phone/Fax

Practice location:
  • Phone: 612-508-0325
  • Fax:
Mailing address:
  • Phone: 612-508-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86106533
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: