Basic Information
| Provider Information | |||||||||
| NPI: | 1376979252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | MOLLIE | ||||||||
| MiddleName: | MARIEDA | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727422 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727422 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 3277 | MN | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 363A00000X | 13962 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.