Healthcare Provider Details

I. General information

NPI: 1184005407
Provider Name (Legal Business Name): MARY K SPENCER RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD
MINNEAPOLIS MN
55416-2527
US

IV. Provider business mailing address

3800 PARK NICOLLET BLVD
MINNEAPOLIS MN
55416-2527
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-2048
  • Fax:
Mailing address:
  • Phone: 952-993-2048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1846
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: