MEDICARE: NOURISHING WAVES NUTRITION PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1528822624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOURISHING WAVES NUTRITION PLLC

Provider Business Mailing Address
First Line	:	4145 42ND AVE S UNIT 2
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-3530
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2124 DUPONT AVE S STE 202
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2719
Country	:	US
Telephone Number	:	952-358-1414
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANNIE CLARKIN
Credential	:	RDN, LD
Telephone Number	:	952-358-1414

Provider Enumeration Date	:	02/08/2024
Last Update Date	:	02/18/2024

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