Provider Demographics
NPI:1497305981
Name:EIKENBERRY, NICOLE SELSTAD (MS, RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SELSTAD
Last Name:EIKENBERRY
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2478
Mailing Address - Country:US
Mailing Address - Phone:612-720-1625
Mailing Address - Fax:
Practice Address - Street 1:905 JEFFERSON AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4740
Practice Address - Country:US
Practice Address - Phone:651-383-5997
Practice Address - Fax:877-533-1363
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN205133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered