Healthcare Provider Details

I. General information

NPI: 1356123392
Provider Name (Legal Business Name): MIKAYLA KOENIG RDN, LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIKAYLA HANKEY

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 NODAK DR S
FARGO ND
58103-2333
US

IV. Provider business mailing address

719 2ND AVE W UNIT 2
WEST FARGO ND
58078-1546
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-6224
  • Fax:
Mailing address:
  • Phone: 701-840-7798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1493
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: