Healthcare Provider Details

I. General information

NPI: 1346522539
Provider Name (Legal Business Name): SHANNON K KRIZKA MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON MOORE

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3393
  • Fax:
Mailing address:
  • Phone: 763-242-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1058178
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: