Healthcare Provider Details

I. General information

NPI: 1164081170
Provider Name (Legal Business Name): ANA FU GUZMAN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE # R5.217
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

3555 34TH AVE S
MINNEAPOLIS MN
55406-2732
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-3623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4034
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: