Provider Demographics
NPI:1093196321
Name:CARLSON, LAUREN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11394 ELDORADO ST NE UNIT D
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4548
Mailing Address - Country:US
Mailing Address - Phone:612-723-6823
Mailing Address - Fax:
Practice Address - Street 1:10961 CLUB WEST PKWY STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5867
Practice Address - Country:US
Practice Address - Phone:763-528-2987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86021401133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered