Healthcare Provider Details

I. General information

NPI: 1548320997
Provider Name (Legal Business Name): LYNETTE LEDUC RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST RM 1904
MANKATO MN
56001-4752
US

IV. Provider business mailing address

130 COPPER MOUNTAIN DR
MANKATO MN
56001-8934
US

V. Phone/Fax

Practice location:
  • Phone: 507-385-6371
  • Fax: 507-385-8560
Mailing address:
  • Phone: 507-385-6371
  • Fax: 507-385-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1675
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: