Provider Demographics
NPI:1568100154
Name:OMUNDSON, TAYLOR BROOKE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:BROOKE
Last Name:OMUNDSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:9300 NOBLE PKWY N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-5500
Practice Address - Country:US
Practice Address - Phone:763-236-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4317133V00000X
MN86104570133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered