Basic Information
| Provider Information | |||||||||
| NPI: | 1770177164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLVARD | ||||||||
| FirstName: | KAELA | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 2645 VIKINGS CIR | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524567600 | ||||||||
| FaxNumber: | 9524567601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2021 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 4220 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.