Healthcare Provider Details

I. General information

NPI: 1154364602
Provider Name (Legal Business Name): REBECCA A DRISCOLL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBECCA BLAKE

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 DORSET RD
MENDOTA HEIGHTS MN
55118-1914
US

IV. Provider business mailing address

1670 ROBERT ST S # 129
WEST ST PAUL MN
55118-3918
US

V. Phone/Fax

Practice location:
  • Phone: 651-276-8018
  • Fax:
Mailing address:
  • Phone: 651-276-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1983
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: