Provider Demographics
NPI:1578120127
Name:ROTHER, MANDY MARIE (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIE
Last Name:ROTHER
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 WASHBURN CIR
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3540
Mailing Address - Country:US
Mailing Address - Phone:763-229-9960
Mailing Address - Fax:
Practice Address - Street 1:2902 CORPORATE PL
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4560
Practice Address - Country:US
Practice Address - Phone:952-229-7014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3282133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered