Basic Information
| Provider Information | |||||||||
| NPI: | 1396114328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDER LAAN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9847 YALTA ST NE | ||||||||
| Address2: | |||||||||
| City: | CIRCLE PINES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550142511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637837321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 913 E 26TH ST STE 401 | ||||||||
| Address2: | MR 39401 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128637622 | ||||||||
| FaxNumber: | 6128638900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2015 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 3329 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.