Provider Demographics
NPI:1417025453
Name:DARA, TASRINA DOWLA (RD)
Entity Type:Individual
Prefix:MRS
First Name:TASRINA
Middle Name:DOWLA
Last Name:DARA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16125 XYLITE ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE X
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5724
Mailing Address - Country:US
Mailing Address - Phone:763-502-6686
Mailing Address - Fax:
Practice Address - Street 1:550 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-3168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2555133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
964412OtherADA REGISTRATION