Provider Demographics
NPI:1104363514
Name:ANDERSON, ELISE F (RD)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:F
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 OAKWOOD AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6708
Mailing Address - Country:US
Mailing Address - Phone:763-656-7159
Mailing Address - Fax:
Practice Address - Street 1:33 MAIN ST S STE 1
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-7507
Practice Address - Country:US
Practice Address - Phone:763-276-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86045878133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered