MEDICARE: CARLY LUNDRY

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	5676	MN

General Provider Information

NPI Number	:	1528922218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY LUNDRY

Provider Business Mailing Address
First Line	:	2905 NORTHWEST BLVD
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55441-7400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2905 NORTHWEST BLVD
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55441-7400
Country	:	US
Telephone Number	:	612-367-4824
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2025
Last Update Date	:	12/16/2025

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Directions to “ CARLY LUNDRY ” Practice Location

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