Healthcare Provider Details

I. General information

NPI: 1902320500
Provider Name (Legal Business Name): KATHERINE VELLABATI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 08/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 TAMARACK RD STE 130
WOODBURY MN
55125-2617
US

IV. Provider business mailing address

4837 HANSON RD
SHOREVIEW MN
55126-5919
US

V. Phone/Fax

Practice location:
  • Phone: 651-265-7575
  • Fax: 651-265-7580
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: