Healthcare Provider Details

I. General information

NPI: 1417215880
Provider Name (Legal Business Name): LISA K HELLEM LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 UNIVERSITY AVE W STE 370
SAINT PAUL MN
55104-3723
US

IV. Provider business mailing address

1690 UNIVERSITY AVE W STE 370
SAINT PAUL MN
55104-3723
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-6929
  • Fax: 651-326-8170
Mailing address:
  • Phone: 651-232-6929
  • Fax: 651-326-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3076
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: