MEDICARE: ALICIA CRISP RD

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	2934	MN

General Provider Information

NPI Number	:	1598146045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA CRISP RD

Provider Business Mailing Address
First Line	:	303 E NICOLLET BLVD STE 200
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-4834
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 E NICOLLET BLVD STE 200
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-4834
Country	:	US
Telephone Number	:	763-502-4877
Fax Number	:

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

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	12/03/2019

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Directions to “ ALICIA CRISP RD” Practice Location

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