Healthcare Provider Details

I. General information

NPI: 1205882784
Provider Name (Legal Business Name): LAURA M KOTOWSKI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 NICOLLET AVE
MINNEAPOLIS MN
55408-4708
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-6963
  • Fax:
Mailing address:
  • Phone: 612-873-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number926190
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: