Provider Demographics
NPI:1417215880
Name:HELLEM, LISA K (LRD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:HELLEM
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 UNIVERSITY AVE W
Mailing Address - Street 2:STE 370
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3723
Mailing Address - Country:US
Mailing Address - Phone:651-232-6929
Mailing Address - Fax:651-326-8170
Practice Address - Street 1:1690 UNIVERSITY AVE W
Practice Address - Street 2:STE 370
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3723
Practice Address - Country:US
Practice Address - Phone:651-232-6929
Practice Address - Fax:651-326-8170
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3076133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1417215880Medicaid
MN710001134Medicare PIN