Provider Demographics
NPI:1104203124
Name:MAGNUSON, LUCIANNE
Entity Type:Individual
Prefix:
First Name:LUCIANNE
Middle Name:
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 4TH ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5301
Practice Address - Country:US
Practice Address - Phone:970-443-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education