Provider Demographics
NPI:1346522539
Name:KRIZKA, SHANNON K (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:K
Last Name:KRIZKA
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:763-242-0778
Mailing Address - Fax:
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1058178133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1058178Medicaid
1058178Medicare Oscar/Certification
1058178Medicare UPIN
WI1058178Medicaid