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NPI Code Detail

MEDICARE: KATHERINE J ELLEFSON RD,CD

MEDICARE: KATHERINE J ELLEFSON RD,CD
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
1133V00000XRegistered Dietitian2694-29WI
2133V00000XRegistered Dietitian3236MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11055136OTHERCOMMISSION ON DIETETIC REGISTRATION

General Provider Information

NPI Number : 1689078834
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHERINE J ELLEFSON RD,CD
Provider Business Mailing Address
First Line : 1146 RIVER RD
Second Line :
City : DRESSER
State : WI
Zip : 54009-4203
Country : US
Telephone Number : 715-417-1705
Fax Number :
Provider Business Practice Location Address
First Line : 6625 LYNDALE AVE S STE 430
Second Line :
City : RICHFIELD
State : MN
Zip : 55423-2300
Country : US
Telephone Number : 952-285-2840
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2014
Last Update Date : 11/19/2020

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