Healthcare Provider Details

I. General information

NPI: 1821908971
Provider Name (Legal Business Name): ELISE AASEMARIE DAVIDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 PARKDALE DR FL 3
ST LOUIS PARK MN
55416-1603
US

IV. Provider business mailing address

1295 BANDANA BLVD N STE 210
SAINT PAUL MN
55108-5115
US

V. Phone/Fax

Practice location:
  • Phone: 888-272-0814
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number6121
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: