Provider Demographics
NPI:1083916654
Name:MEHLE BONACH, BRENNA R
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:R
Last Name:MEHLE BONACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:R
Other - Last Name:MEHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-5179
Practice Address - Fax:952-993-5817
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2907133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered