Basic Information
| Provider Information | |||||||||
| NPI: | 1720703275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREKKEN | ||||||||
| FirstName: | ABIGAIL | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3649 147TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | HAM LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553044691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514259840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1540 LAKE ST S | ||||||||
| Address2: | |||||||||
| City: | FOREST LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550252628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514647100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2022 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/06/2022 | ||||||||
| NPIReactivationDate: | 10/18/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 3311 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.