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General NPI Number Information
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NPI Number | 1114359205
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Entity Type | Individual
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Provider Name | KONNIE SUE LUCZAK RD, LD
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Gender | Female
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Dates
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Enumeration Date | 07/31/2013
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 237 RADIO DR STE 210
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City | WOODBURY
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State | MN
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Zip | 55125-4478
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Country | US
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Telephone | 612-871-1145
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Fax | 612-870-5491
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Provider Business Mailing Address
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Address Line | 1900 CENTRACARE CIR CENTRACARE CLINIC HEALTH PLAZA
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City | SAINT CLOUD
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State | MN
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Zip | 56303-5000
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Country | US
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Telephone | 320-229-4916
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Fax | 320-229-5174
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 3245
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License Number State | MN
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