Provider Demographics
NPI:1235501412
Name:HILL, GWENDA LYN (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:GWENDA
Middle Name:LYN
Last Name:HILL
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 WEST BROADWAY AVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445
Mailing Address - Country:US
Mailing Address - Phone:763-587-7900
Mailing Address - Fax:763-587-7066
Practice Address - Street 1:15655 37TH AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446
Practice Address - Country:US
Practice Address - Phone:763-587-7900
Practice Address - Fax:763-587-7701
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2963133V00000X
MN1034183133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered