Provider Demographics
NPI:1194231654
Name:HALVERSON, KATIE JANE (RD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JANE
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JANE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:10 7TH AVE N APT 306
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-8848
Mailing Address - Country:US
Mailing Address - Phone:218-242-2429
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:218-242-2429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86022117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered