Basic Information
| Provider Information | |||||||||
| NPI: | 1124180625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | GEORGIANNA | ||||||||
| MiddleName: | FAYE | ||||||||
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| Credential: | REGISTERED DIETITIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2108 RED TAIL LN | ||||||||
| Address2: | |||||||||
| City: | NORTH MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560031651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073888458 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3525 MONTEREY DR | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554165275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1595 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.