Provider Demographics
NPI:1407509813
Name:CRUM, AMY BRYCE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BRYCE
Last Name:CRUM
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:BRYCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:15809 WHITE PINE DR
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2122
Mailing Address - Country:US
Mailing Address - Phone:512-796-1880
Mailing Address - Fax:
Practice Address - Street 1:1250 WAYZATA BLVD E
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1951
Practice Address - Country:US
Practice Address - Phone:952-345-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3390133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered