Provider Demographics
NPI:1124180625
Name:ELLIOTT, GEORGIANNA FAYE (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:GEORGIANNA
Middle Name:FAYE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 RED TAIL LN
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1651
Mailing Address - Country:US
Mailing Address - Phone:507-388-8458
Mailing Address - Fax:
Practice Address - Street 1:3525 MONTEREY DR
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5275
Practice Address - Country:US
Practice Address - Phone:952-993-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1595133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered