Healthcare Provider Details

I. General information

NPI: 1396114328
Provider Name (Legal Business Name): ELIZABETH J VANDER LAAN MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 E 26TH ST STE 401 MR 39401
MINNEAPOLIS MN
55404-4515
US

IV. Provider business mailing address

9847 YALTA ST NE
CIRCLE PINES MN
55014-2511
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-7622
  • Fax: 612-863-8900
Mailing address:
  • Phone: 763-783-7321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3329
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: