Healthcare Provider Details

I. General information

NPI: 1912379181
Provider Name (Legal Business Name): LUCY CHERMAK RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 COMO AVE
SAINT PAUL MN
55108-1720
US

IV. Provider business mailing address

400 S 4TH STREET STE 410 PMB 89104
MINNEAPOLIS MN
55415-1720
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-5323
  • Fax:
Mailing address:
  • Phone: 651-206-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2981
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: