Healthcare Provider Details

I. General information

NPI: 1144525627
Provider Name (Legal Business Name): NANCY J GUSTAFSON LUTHI MS, RD, CDE, CSOWM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANCY J GUSTAFSON MS, RD, FADA

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2101 ELM ST N
FARGO ND
58102-2417
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax:
Mailing address:
  • Phone: 701-239-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number237
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3191
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number3191
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number237
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: