Provider Demographics
NPI:1164844304
Name:MEZERA, MICHELLE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MEZERA
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 1:500 OSBORNE RD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:763-236-2045
Mailing Address - Fax:
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-236-2045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2940133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered